Intraoperative Estimated Blood Loss Research Articles

Age- and sex-related differences in risk factors for perioperative intra-aortic balloon pump application in patients undergoing coronary artery bypass grafting

BackgroundAn intra-aortic balloon pump (IABP) is a mechanical circulatory device frequently used in patients undergoing coronary artery bypass grafting (CABG). As a treatment for perioperative haemodynamic instability, IABP insertion often implicates an adverse outcome. This study aimed to investigate the age- and sex-related disparity in risk factors for perioperative IABP insertion in CABG patients.MethodsA total of 2,460 CABG patients were included and divided into subgroups by age (elderly subgroup, ≥65 years; young subgroup, <65 years) and sex. Basic characteristics were compared between IABP and non-IABP patients in the overall patient group and the subgroups. Multivariate logistic analysis was used to investigate the significant risk factors for perioperative IABP application, and interaction effects among the potential risk factors were analysed. Combined receiver operating characteristic analysis was used to evaluate the prediction value of combined risk factors.ResultsThe overall patient group had a mean age of 61.5 years. The application rate of perioperative IABP was 8.0%. A left ventricular ejection fraction (LVEF) <50% significantly correlated with perioperative IABP application in the overall patient group and the subgroups. Traditional factors such as myocardial infarction history, atrial fibrillation history, and intraoperative estimated blood loss were significant risk factors in certain subgroups. Small dense low-density lipoprotein levels were significantly associated with IABP insertion in the male subgroup and young subgroup. The area under the curve of combined risk factors was significantly higher than that of LVEF <50% alone in the overall patient group and subgroups.ConclusionAge- and sex-related differences were present in the risk factor distribution for perioperative IABP insertion in CABG patients.

Association between delayed ambulation and increased risk of adverse events after lumbar fusion surgery in elderly patients

PurposeThe relationship between delayed ambulation (DA) and postoperative adverse events (AEs) following transforaminal lumbar interbody fusion (TLIF) in elderly patients remains elusive. The aim of our study was to evaluate the effects of DA on the postoperative AEs including complications, readmission and prolonged length of hospital stay (LOS).MethodsThis was a retrospective analysis of a prospectively established database of elderly patients (aged 65 years and older) who underwent TLIF surgery. The early ambulation (EA) group was defined as patients ambulated within 48 h after surgery, whereas the delayed ambulation (DA) group was patients ambulated at a minimum of 48 h postoperatively. The DA patients were 1:1 propensity-score matched to the EA patients based on age, gender and the number of fused segments. Univariate analysis was used to compare postoperative outcomes between the two groups, and multivariate logistic regression analysis was used to identify risk factors for adverse events and DA.ResultsAfter excluding 125 patients for various reasons, 1025 patients (≤ 48 h: N = 659 and > 48 h: N = 366) were included in the final analysis. After propensity score matching, there were 326 matched patients in each group. There were no significant differences in the baseline data and the surgery-related variables between the two groups (p > 0.05). The patients in the DA group had a significant higher incidence of postoperative AEs (46.0% vs. 34.0%, p = 0.002) and longer LOS (p = 0.001). Multivariate logistic regression identified that age, operative time, diabetes, and DA were independently associated with postoperative AEs, whereas greater age, higher international normalized ratio, and intraoperative estimated blood loss were identified as independent risk factors for DA.ConclusionsDelayed ambulation was an independent risk factor for postoperative AEs after TLIF in elderly patients. Older age, increased intraoperative blood loss and worse coagulation function were associated with delayed ambulation.

How Much Does Intravenous Fluid Cause Hematocrit to Drop? Improving Interpretation of Hematocrit Toward Better Post-Hemorrhage Care.

Hemorrhage is assessed, at least in part, via hematocrit testing. To differentiate unexpected drops in hematocrit because of ongoing hemorrhage versus expected drops as a result of known hemorrhage and intravenous fluid administration, we model expected post-operative hematocrit values accounting for fluid balance and intraoperative estimated blood loss (EBL) among patients without substantial post-operative bleeding. We reviewed patient-level data from the electronic health record of an academic medical center for all non-pregnant adults admitted for elective knee or hip arthroplasty from November 2013 to September 2022 who did not require blood products. We used linear regression to evaluate the association between post-operative hematocrit and predictor variables including pre-operative hematocrit, intraoperative net fluid intake, blood volume, time from surgery to lab testing, EBL, patient height, and patient weight. We included 6,648 cases. Mean (SD) estimated blood volume was 4,804 mL (1023), mean net fluid intake was 1,121 mL (792), and mean EBL was 144 mL (194). Each 100 mL of EBL and 1,000 mL net positive fluid intake was associated with a decrease of 0.52 units (95% CI, 0.51-0.53) and 2.4 units (2.2-2.7) in post-operative hematocrit. Pre-operative hematocrit was the strongest predictor of post-operative hematocrit. Each 1-unit increase in pre-operative hematocrit was associated with a 0.70-unit increase (95% CI, 0.67-0.73) in post-operative hematocrit. Our estimates were robust to sensitivity analyses, and all variables included in the model were statistically significant with P <.005. Patient-specific data, including fluid received since the time of initial hemorrhage, can aid in estimating expected post-hemorrhage hematocrit values, and thus in assessing for the ongoing hemorrhage.

Restoring L4-S1 Lordosis Shape in Severe Sagittal Deformity: Impact of Correction Techniques on Alignment and Complication Profile

Severe sagittal plane deformity with loss of L4-S1 lordosis is disabling and can be improved through various surgical techniques. However, data is limited on the differing ability of anterior lumbar interbody fusion (ALIF), pedicle subtraction osteotomy (PSO), and transforaminal lumbar interbody fusion (TLIF) to achieve alignment goals in severely malaligned patients. To examine surgical techniques aimed at restoring L4-S1 lordosis in severe adult spinal deformity (ASD). Retrospective review of prospectively collected data. A total of 96 patients who underwent ALIF, PSO, and TLIF were included in this study. The following data were observed for all cases: patient demographics, spinopelvic parameters, complications, and PROMs. Severe ASD patients with preoperative PI-LL >20°, L4-S1 lordosis <30°, and full body radiographs and patient-reported outcome measures (PROMs) at baseline and six-week postoperative visit were included. Patients were grouped into ALIF (1-2 level ALIF at L4-S1), PSO (L4/L5 PSO), and TLIF (1-2 level TLIF at L4-S1). Comparative analyses were performed on demographics, radiographic spinopelvic parameters, complications, and PROMs. Among the 96 included patients, 40 underwent ALIF, 27 underwent PSO, and 29 underwent TLIF. At baseline, cohorts had comparable age, sex, race, Edmonton frailty scores and radiographic spinopelvic parameters (p>0.05). However, PSO was performed more often in revision cases (p<0.001). Following surgery, L4-S1 lordosis correction (p=0.001) was comparable among ALIF and PSO patients and caudal lordotic apex migration (p=0.044) was highest among ALIF patients. PSO patients had higher intraoperative estimated blood loss (p<0.001) and motor deficits (p=0.049), and in-hospital ICU admission (p=0.022) and blood products given (p=0.004) but were otherwise comparable in terms of length of stay, blood transfusion given, and postoperative admission to rehab. Likewise, 90-day postoperative complication profiles and six-week PROMs were comparable as well. ALIF can restore L4-S1 sagittal alignment as powerfully as PSO, with fewer intra-operative and in-hospital complications. When feasible, ALIF is a suitable alternative to PSO and likely superior to TLIF for correcting L4-S1 lordosis among patients with severe sagittal malalignment.

Safety and Efficacy of Tranexamic Acid in Spinal Surgery: A Systematic Review and Meta-Analysis.

Tranexamic acid (TXA) has gained popularity in spinal surgery because of its potential to reduce blood loss. However, concerns regarding its safety and efficacy remain. This systematic review and meta-analysis aimed to evaluate the efficacy of TXA in reducing blood loss and its safety profile in spinal surgeries. A comprehensive search was conducted in electronic databases for randomized controlled trials and prospective studies evaluating the use of TXA in spinal surgery. The primary outcomes were intraoperative and total estimated blood loss (EBL), and the secondary outcomes included the incidence and types of complications associated with TXA use. Meta-analyses were performed using random-effects models. Thirteen studies involving 1,213 participants were included in the meta-analysis. The use of TXA was associated with significant reductions in both intraoperative (mean difference: -46.56 mL [-73.85, -19.26], p<0.01]) and total EBL (mean difference: -210.17 mL [-284.93, -135.40], p<0.01) while also decreasing the need for blood transfusions (risk ratio: 0.68 [0.51, 0.90], p<0.01). No significant difference was found in the incidence and types of thrombotic complications when TXA was used in spinal surgery. Subgroup analysis showed consistent results in instrumentation and fusion surgery and different doses of TXA. TXA is effective in reducing intraoperative and overall blood loss in spinal surgery without increasing the risk of complications. These findings support the use of TXA to improve patient outcomes. However, caution should be exercised because of the heterogeneity among the included studies. Further research is needed to confirm these findings and explore potential long-term complications.

The 5-Item Modified Frailty Index as a Predictor of Postoperative Outcomes in Thoracic Metastatic Epidural Spinal Cord Compression

BackgroundPatients with thoracic metastatic epidural spinal cord compression (MESCC) often undergo extensive surgical decompression to avoid functional decline. Though limited in scope, scales including the revised cardiac risk index (RCRI) are used to stratify surgical risk to predict perioperative morbidity. This study uses the 5-item modified frailty index (mFI-5) to predict outcomes following transpedicular decompression/fusion for high-grade MESCC. MethodsA retrospective chart review was conducted on patients who underwent transpedicular decompression and fusion for MESCC (baseline demographics, spinal instability neoplastic score, preoperative and postoperative Bilsky scores, primary cancer type, RCRI). Primary outcomes included length of stay (LOS), intraoperative estimated blood loss, readmission/reoperation within 90 days of index surgery, 90-day mortality, and post-hospitalization disposition. Results127 patients were included in our study. 90% of patients’ lesions were Bilsky 2 or greater. Increasing frailty, measured by mFI-5, was a significant predictor of increased LOS (p<0.01) and 90-day mortality (p<0.05). Multivariate analysis adjusting for sex, BMI, and age still showed statistical significance (p<0.05). MFI-5 was not a significant predictor of readmission/reoperation within 90 days or estimated blood loss. Age – not mFI-5 or RCRI – was a significant predictor for posthospitalization non-home disposition (p=0.001). ConclusionsThe mFI-5 can serve as a useful predictor of outcomes after transpedicular decompression and fusion for thoracic MESCC as it can account for the patient's frailty. Our study demonstrated the mFI-5 as a predictor of LOS and 90-day mortality. These results provide a background to both understanding and integrating frailty into decision-making in MESCC.

A comparative retrospective analysis on robot-assisted laparoscopic surgery compared to conventional laparoscopy in case of myomectomy: experience in a third-level hospital of Southern Italy.

Uterine myomas are the most common gynecological disease in reproductive-aged women, present several symptoms, and require effective medical and/or surgical strategies. This study aimed to compare robotic-assisted laparoscopic myomectomy (RALM) with laparoscopic myomectomy (LM) in terms of operative times, intraoperative estimated blood loss, pre- and post-hemoglobin levels drop, and length of hospital stay. Data from 50 clinical records (25 RALM in Group A and 25 LM in Group B) of patients with uterine fibroids were collected from December 2022 to December 2023 at Gynecological Unit of DAI Materno-Infantile Federico II in Naples, Italy. Patients aged 30-49years with symptomatic fibroids were included. Data on peri-operative outcomes, including operative time for myomectomy (OTM), overall operative time (OOT), intraoperative estimated blood loss (EBL), pre- and post-operative hemoglobin levels, and length of hospital stay were analyzed. The OTM in the presence of > 5 myomas was 59 [52-65] vs 69min [61-96] (p < 0.001) for RALM and LM groups, respectively. Moreover, also in presence of ≤ 5 myomas, a difference was observed in the RALM group 48[43-55] compared to the LM group 53[50-61] min (p = 0.07). The OOT was also statistically significant for Group A compared to Group B (83[65-93] vs 72[56-110] min, p < 0.001). There were no significant differences between the two groups in terms of pre- and post-operative hemoglobin levels and EBL (p = 0.178). Group A demonstrated a notably shorter hospital stay 1.2 [1-2] days compared to Group B 2.9[3-3.75] days (p = 0.007). Our study suggests potential advantages of RALM over LM in terms of reduced operative times and shorter hospital stays. The standardized approach and extensive surgical experience likely contributed to the favorable outcomes of RALM.

Marital status shows no protective effect on perioperative outcomes after robotic-assisted pulmonary lobectomy

BackgroundMarital status has been shown to have protective effects for married patients with various cancers. We sought to determine effects of marital status on perioperative outcomes after robotic-assisted pulmonary lobectomy (RAPL). MethodsWe retrospectively analyzed 709 consecutive patients who underwent RAPL between 2010 and 2022 by one surgeon. Patients were stratified by marital status at time of surgery. The Married group included married, domestically partnered, and co-habitating patients (N = 473). The Unmarried group included never married, divorced, and widowed individuals (N = 236). Demographics, preoperative comorbidities, intraoperative and postoperative complications, estimated blood loss (EBL), chest tube duration, hospital length of stay (LOS), tumor characteristics, and survival data were analyzed utilizing Student's t-test, Wilcoxon rank-sum test, Chi-square, or Fisher's exact test as appropriate, with significance at p≤0.05. ResultsUnmarried patients were more likely to be female, while married patients were more likely to experience robotic-associated intraoperative complications and greater intraoperative estimated blood loss. Kaplan-Meier survival analysis revealed no difference in 5-year overall survival based on marital status. Other perioperative outcomes, intraoperative complications (except robotic-associated), postoperative complications, demographic history (except gender), and preoperative comorbidities did not significantly differ between the two groups. ConclusionThis study challenges the existing reports in the literature that marriage confers cancer treatment outcomes advantage and prolonged survival among cancer patients. Social support, in terms of a spouse or domestic partner, may be less protective in early-stage lung cancer and after minimally invasive pulmonary lobectomy compared to other cancer populations.

Clinical outcomes and challenges of surgical extirpation for carotid body paraganglioma in South Korea: a single-center retrospective study

BackgroundCarotid body paraganglioma (CBP) is a rare, highly vascularized, and slow-growing neuroendocrine tumor. Surgical resection is the definitive treatment for CBP, however, it remains challenging due to the tumor’s proximity to critical blood vessels and cervical cranial nerves. This study aimed to document the characteristics of CBP and examine the clinical outcomes of patients following surgical extirpation of CBP.MethodsThis is a single-center retrospective review analyzed patients who underwent CBP extirpation. We examined the patient demographics, preoperative clinical features, tumor characteristics, levels of catecholamines and their metabolites in the serum and urine. Surgeries were performed by one vascular surgeon with follow-ups at 1,3,6 months and yearly thereafter. Logistic regression analysis was conducted to identify risk factors associated with the occurrence of either permanent or temporary cervival cranial nerve palsy (CNP).ResultsFrom September 2020 to February 2023, this study examined 21 cases of CBP removal surgeries that were carried out in 19 patients. The mean age of the patients was 38.9 ± 10.9 years and the percentage of males was 57.1% (n = 12). The most common preoperative clinical feature was painless neck mass (n = 12; 57.1%). Complete resection was achieved in 20 cases; excluding one case with pathologically proven sclerosing paraganglioma. Vascular procedures were performed in four cases (ECA resection, n = 2; primary repair of ICA tear without carotid shunting, n = 1; and ICA patch angioplasty with carotid shunting, n = 1). Temporary cranial neurologic complications, specifically aspiration and hoarseness occurred in four (19.0%), and three (14.3%) cases, respectively. Hoarseness associated with permanent CNP persisted for more than 6 months in two cases (9.5%). No recurrence or mortality was observed during the follow-up period.ConclusionsSurgical resection is the primay treatment approach for CBP; however, it poses risks of vascular or cervical CNP. The intraoperative estimated blood loss was the only identified risk factor for CNP.

Robotic gastrectomy was reliable option for overweight patients with gastric cancer: a propensity score matching study.

The role of minimally invasive surgery using robotics versus laparoscopy in resectable gastric cancer patients with a high body mass index (BMI) remains controversial. A total of 482 gastric adenocarcinoma patients with BMI ≥ 25 kg/m2 who underwent minimally invasive radical gastrectomy between August 2016 and December 2019 were retrospectively analyzed, including 109 cases in the robotic gastrectomy (RG) group and 321 cases in the laparoscopic gastrectomy (LG) group. Propensity score matching (PSM) with a 1:1 ratio was performed, and the perioperative outcomes, lymph node dissection, and 3-year overall survival (OS) and disease-free survival (DFS) rates were compared. After PSM, 109 patients were included in each of the RG and LG groups, with balanced baseline characteristics. Compared with the LG group, the RG group had similar intraoperative estimated blood loss [median (IQR) 30 (20-50) vs. 35 (30-59) mL, median difference (95%CI) - 5 (- 10 to 0)], postoperative complications [13.8% vs. 18.3%, OR (95%CI) 0.71 (0.342 to 1.473)], postoperative recovery, total harvested lymph nodes [(34.25 ± 13.43 vs. 35.44 ± 14.12, mean difference (95%CI) - 1.19 (-4.871 to 2.485)] and textbook outcomes [(81.7% vs. 76.1%, OR (95%CI) 1.39 (0.724 to 2.684)]. Among pathological stage II-III patients receiving chemotherapy, the initiation of adjuvant chemotherapy in the RG group was similar to that in the LG group [median (IQR): 28 (25.5-32.5) vs. 32 (27-38.5) days, median difference (95%CI) - 3 (- 6 to 0)]. The 3-year OS (RG vs. LG: 80.7% vs. 81.7%, HR = 1.048, 95%CI 0.591 to 1.857) and DFS (78% vs. 76.1%, HR = 0.996, 95%CI 0.584 to 1.698) were comparable between the two groups. RG conferred comparable lymph node dissection, postoperative recovery, and oncologic outcomes in a selected cohort of patients with BMI ≥ 25 kg/m2.

Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis?

Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes. Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age. Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes. COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems. Level III-prognostic study.

Comparison of Clinical Effects of Cortical Bone Trajectory Screws and Traditional Pedicle Screws in Posterior Lumbar Fusion

To compare the clinical effects of cortical bone trajectory screws and traditional pedicle screws in posterior lumbar fusion. A retrospective study was conducted to analyze lumbar degeneration patients who underwent surgical treatment at our hospital between January 2016 and January 2019. A total of 123 patients who met the inclusion criteria were enrolled. The subjects were divided into two groups according to their surgical procedures and the members of the two groups were matched by age, sex, and the number of fusion segments. There were 63 patients in the traditional pedicle screws (PS) group and 60 in the cortical bone trajectory screws (CBTS) group. The outcomes of the two groups were compared. The primary outcome measures were perioperative conditions, including operation duration, estimated intraoperative blood loss (EBL), and length-of-stay (LOS), visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, and interbody fusion rate. The secondary outcome measures were the time to postoperative ambulation and the incidence of complications. VAS scores and ODI scores were assessed before operation, 1 week, 1 month, 3 months, and 12 months after operation, and at the final follow-up. The interbody fusion rate was assessed in 1 year and 2 years after the operation and at the final follow-up. The CBTS group showed a reduction in operation duration ([142.8±13.1] min vs. [174.7±15.4] min, P<0.001), LOS ([9.5±1.5] d vs. [12.0±2.0] d, P<0.001), and EBL ([194.2±38.3] mL vs. [377.5±33.1] mL, P<0.001) in comparison with the PS group. The VAS score for back pain in the CBTS group was lower than that in the PS group at 1 week and 1 month after operation and the ODI score in the CBTS group was lower than that in the PS group at 1 month after operation, with the differences being statistically significant (P<0.05). At each postoperative time point, the VAS score for leg pain and the interbody fusion rate did not show significant difference between the two groups. The VAS score for back and leg pain and the ODI score at each time point after operation in both the CBTS group and the PS group were significantly lower than those before operation (P<0.05). No significant difference was found in the time to postoperative ambulation or the overall complication incidence between the two groups. The CBTS technique could significantly shorten the operation duration and LOS, reduce EBL, and achieve the same effect as the PS technique does in terms of intervertebral fusion rate, pain relief, functional improvement, and complication incidence in patients undergoing posterior lumbar fusion.

Patients with chronic kidney disease can expect significant improvement in pain and function after shoulder arthroplasty

BackgroundChronic kidney disease (CKD) is associated with negative outcomes after hip and knee arthroplasty due to higher rates of infection, aseptic loosening, and transfusion. The purpose of this study was to compare clinical outcome scores and complication rate after shoulder arthroplasty (SA) for patients with and without CKD. MethodsWe conducted a retrospective cohort study of prospectively collected data and reviewed all patients who underwent primary SA from January 2015 to December 2019 by one surgeon at one institution. Revision arthroplasty patients were excluded. We evaluated results from patients with CKD (glomerular filtration rate [GFR] ≤ 59) and without CKD (GFR ≥ 60). Outcome measures including visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores were compared between cohorts. Minimum clinically important difference (MCID) and substantial clinical benefit also were determined for this cohort. Univariate and multivariable regression was performed to assess the influence of CKD on outcome measures and risk of complications. Results518 patients met inclusion criteria; 4 patients did not have recorded GFR, leaving 514 patients for analysis. 389 patients had normal GFR; 125 had CKD. Patients with CKD had lower overall preoperative and postoperative ASES, SST, and SANE scores but demonstrated similar levels of clinical improvement from preoperative to postoperative time points (Δ ASES 41.4 ± 21.8 vs. 42.9 ± 21.4, P = .55), (Δ SST 4.8 ± 3.4 vs. 4.9 ± 3.3, P = .08), (Δ SANE 40.7 ± 29.1 vs. 42.4 ± 26.5, P = .77). Both cohorts achieved MCID for ASES, SST, and SANE scores. Univariately, patients with CKD were at high risk to require transfusion (OR 16.2 (1.9, 139.7), P = .01) despite similar intraoperative estimated blood loss (156.9 ± 132.5mL vs. 153.8 ± 89.7mL, P = .77). CKD patients also were at higher risk for intraoperative fracture (OR 5.4 (1.3, 23.0), P = .02). CKD patients were not at higher risk for prosthetic joint infection (OR 3.2 (0.2, 50.8), P = .42), medical complications (OR 0.9 (0.2, 4.4), P = .89), or revision (OR 1.9 (0.7, 4.9), P = .19) in this cohort. Multivariable analysis of any complication after SA demonstrated that renal disease was not an independent risk factor for overall complication risk in this cohort (OR 1.1 (0.7, 1.8) P = .650). ConclusionSurgeons can be assured that patients who have CKD achieve similar gains in clinical outcomes as other patients. Despite experiencing a higher risk for transfusion and intraoperative fracture, renal disease was not an independent risk factor for complications after SA in this small cohort.

Determination of Whole Blood Loss From Minimally Invasive Myomectomy Using a Standardized Formula: A Pilot Study

Study ObjectiveTo determine the median perioperative blood loss (PBL) during minimally invasive surgical (MIS) myomectomy. DesignProspective pilot study. SettingLarge academic teaching hospital. PatientsThirty-one patients underwent laparoscopic or robotic myomectomy and completed a postoperative complete blood count (CBC) from November 2020 to August 2022. Patients had to have at least one fibroid greater than or equal to 3 cm on preoperative imaging. InterventionsA CBC was collected preoperatively within 7 days of surgery. Estimated blood loss (EBL) was determined by the surgeon intraoperatively. A repeat CBC was drawn between postoperative days 2 through 4. PBL was calculated using the equation PBL = (patient weight in kg × 65 cc/kg) × (preoperative hematocrit − postoperative hematocrit)/preoperative hematocrit. Measurements and Main ResultsMedian PBL (536.3 cc [270.0, 909.3]) was greater than median EBL (200.0 cc [75.0, 500.0]). PBL ranged from a net gain of 191.5 cc to net loss of 2362.5 cc. Median size of the largest fibroid on preoperative imaging was 8.8 cm (6.6, 11.5), and median weight of fibroids removed was 321 g (115, 519). About half of patients (51.6%) had one fibroid removed, and 48.4% had 2 or more fibroids removed. Five patients were converted to laparotomy, 4 from robotic approaches. Two patients required a blood transfusion. ConclusionCalculated PBL was greater than intraoperative EBL. This suggests there is continued blood loss post myometrial bed closure. Blood loss should be evaluated both during and after myomectomy, as intraoperative EBL underestimates total PBL.

The Hidden Risks of Perioperative Transfusions in Traumatic Lower Extremity Free Flap Reconstruction.

Blood transfusions have been associated with surgical complications; however, these studies are not specific to lower extremity (LE) reconstruction. We evaluated the effect of perioperative packed red blood cell (PRBC) transfusions on LE free flap outcomes in trauma patients. Patients undergoing LE free flap reconstruction following acute injuries from 2016 to 2021 were retrospectively analyzed. The perioperative period for transfusions was defined as ± 3 days from the procedure. Parameters included demographics, perioperative characteristics, and outcomes. Major complications were complications requiring reoperation. Univariate and multivariate analyses were performed to identify associations. Of the 205 patients, 48% received PRBCs perioperatively. There was a trend toward higher major complications rate in the transfusion group (19 vs. 10%, p = 0.09). Wound size, injury severity score (ISS), and intraoperative estimated blood loss were greater in the transfusion group (p < 0.01). Preoperative hemoglobin/hematocrit were lower in the transfusion group (p < 0.001). Units of PRBCs transfused were independently associated with major complications on multivariate analysis (odds ratio [OR] = 1.34, confidence interval [CI]: 1.06-1.70, p = 0.015) and length of hospital stay (LOS; OR = 1.05, CI: 1.02-1.08, p = 0.002). Infection, wound size, ISS, and preoperative hemoglobin/hematocrit were independently associated with increased LOS (p < 0.05) but not with major complications. The number of units of PRBCs given perioperatively was the only variable independently associated with major complications on multivariate analysis and was one of many variables associated with increased LOS. These findings suggest the usage of restrictive transfusion protocols in trauma patients requiring LE reconstruction.

A Retrospective Comparative Analysis on the Effect of Tranexamic Acid to Reduce Perioperative Blood Loss in Patients Undergoing Cervical Spine Surgery.

Retrospective Cohort Study. The purpose of this study is to assess the impact of intravenous TXA on blood loss outcomes in anterior, posterior, and combined approaches for elective cervical spine surgery. Tranexamic acid (TXA) has been shown to reduce blood loss in a variety of operations, such as lumbar spine surgery. However, limited studies have evaluated the efficacy of TXA in cervical spine surgery. We performed a retrospective review of a single surgeon's elective cervical spine operations between September 2011 and March 2017. Patients were divided into 3 groups: anterior approach, posterior approach, or combined approach. Patients were then further subdivided into TXA versus control groups based on whether they received TXA treatment. We performed multiple linear regressions to assess the relationship between the use of TXA and other dependent variables (number of vertebral levels treated, need for a vertebral corpectomy) on total perioperative blood loss, intraoperative estimated blood loss, postoperative drain output, total operative time, postoperative change in hemoglobin, and occurrence of transfusion and/or postoperative deep venous thrombus (DVT). We found that the use of TXA statistically significantly reduced total perioperative blood loss ( P =0.04) and postoperative drain output ( P =0.004) in posterior surgical approach cervical spine surgery but did not statistically significantly impact any blood loss variables in anterior or combined surgical approaches to elective cervical spine surgery. The use of TXA was a significant predictor for a decrease in intraoperative ( P =0.02) and postoperative ( P <0.01) blood loss. This study found that TXA statistically significantly decreased total blood loss and postoperative drain output when controlling for multiple confounding factors. Level III.

Examining the utility of routine perioperative hemoglobin monitoring in patients undergoing radical nephrectomy.

Patients undergoing radical nephrectomy (RN) are often admitted with protocolized bloodwork for several days following their operation, yet the clinical value of serial hemoglobin (Hgb) measurements has not been established. This can lead to unnecessary costs and can prolong patient stay, despite the absence of an intervention based on these lab values. This study sought to examine perioperative Hgb values and identify those patients at high risk of bleeding requiring intervention, as well as those patients who are unlikely to require further monitoring. Patient and perioperative factors were retrospectively examined for a cohort of 259 radical nephrectomy patients from 2015-2021 in Atlantic Canada. Postoperative Hgb values and transfusion rates were recorded. A multivariate logistic regression analysis was performed to identify variables associated with requiring a blood transfusion. Overall, 31 (12%) patients required a blood transfusion in the postoperative period. Median estimated blood loss (EBL) was 150 (interquartile range [IQR] 100-300) ml, with a median Hgb change of 15 (IQR 9-22) g/L from preoperative to postoperative day 1 (POD1). In patients with a Hgb loss of ≤15 g/L (n=131), transfusion was only required in four patients (3.1%). Among those with a POD1 Hgb >100 g/L (n=199), only four (2%) required transfusion. These patients were identified as having complications based on hemodynamic instability. On multivariate regression analysis, factors found to be associated with higher transfusion risk were age and intraoperative EBL, while higher preoperative Hgb was found to be associated with a lower transfusion risk. In patients who have a reassuring POD1 Hgb value, with a drop of <15 g/L or an absolute value of >100 g/L, consideration can be made towards discontinuing routine Hgb testing in the absence of a clinical indication. Age, blood loss, and preoperative Hgb are factors that may affect a patient's overall risk of transfusion.

Automated deep learning model for estimating intraoperative blood loss using gauze images

The intraoperative estimated blood loss (EBL), an essential parameter for perioperative management, has been evaluated by manually weighing blood in gauze and suction bottles, a process both time-consuming and labor-intensive. As the novel EBL prediction platform, we developed an automated deep learning EBL prediction model, utilizing the patch-wise crumpled state (P-W CS) of gauze images with texture analysis. The proposed algorithm was developed using animal data obtained from a porcine experiment and validated on human intraoperative data prospectively collected from 102 laparoscopic gastric cancer surgeries. The EBL prediction model involves gauze area detection and subsequent EBL regression based on the detected areas, with each stage optimized through comparative model performance evaluations. The selected gauze detection model demonstrated a sensitivity of 96.5% and a specificity of 98.0%. Based on this detection model, the performance of EBL regression stage models was compared. Comparative evaluations revealed that our P-W CS-based model outperforms others, including one reliant on convolutional neural networks and another analyzing the gauze’s overall crumpled state. The P-W CS-based model achieved a mean absolute error (MAE) of 0.25 g and a mean absolute percentage error (MAPE) of 7.26% in EBL regression. Additionally, per-patient assessment yielded an MAE of 0.58 g, indicating errors < 1 g/patient. In conclusion, our algorithm provides an objective standard and streamlined approach for EBL estimation during surgery without the need for perioperative approximation and additional tasks by humans. The robust performance of the model across varied surgical conditions emphasizes its clinical potential for real-world application.

Impact of gasless vNOTES vs. traditional vNOTES on hemodynamic profiles and outcomes in patients with benign gynecological disease: study protocol of a randomized controlled trial

BackgroundLiterature regarding the advantages of gasless vNOTES is insufficient. The aim of our study is to compare gasless vNOTES vs. traditional vNOTES on hemodynamic profiles and outcomes in patients with benign gynecological disease. We hypothesize that compared with those in the traditional vNOTES group, hemodynamic profiles will be changed less during gasless vNOTES, while safety can be promised.MethodsThis is a single-center, prospective, single-blind, randomized controlled clinical trial, which has been approved by the Institutional Review Board of Chengdu Women’s and Children’s Hospital on September 27, 2022. One hundred and twenty patients will be recruited and randomly assigned to either the traditional vNOTES group or the gasless vNOTES group in a 1:1 ratio. For patients allocated to the traditional vNOTES group, after insertion of one port through the vagina, CO2 gas is infused with a pressure of 12–14 mmHg; while for those allocated to the gasless vNOTES group, a special device is used as an abdominal wall-lifting device to facilitate gasless surgery. CO2 pneumoperitoneum will not be used during the whole gasless vNOTES procedure. The primary outcome is vital signs at different time points. The secondary outcomes include surgical conversion rate, duration of surgery and anesthesia, anesthetic consumption, intraoperative estimated blood loss, VAS and PONV scores at postoperative 2 h and 24 h, administration of vasopressor drugs from the beginning of general anesthesia induction to 15 min after endotracheal intubation, including times, dosage, and type, intraoperative and postoperative complications, time of first getting out of bed after surgery, and time of first eating after surgery, including light drink.DiscussionThis is the first randomized controlled trial to compare the impacts of gasless vNOTES vs. traditional vNOTES on hemodynamic profiles and outcomes in patients with benign gynecological disease. If a favorable effect and safety of gasless vNOTES for hemodynamic profiles and outcomes in patients are shown, gasless vNOTES would be an optimal treatment option for patients with benign gynecological disease.Trial registrationThe trial was registered at https://www.chictr.org.cn/showproj.html?proj=182441 with registration No. ChiCTR2200064779 on Oct 17, 2022.

Oral and intravenous tranexamic acid administration demonstrate no significant difference in objective measures of blood loss in primary total shoulder arthroplasty

IntroductionThe routine use of tranexamic acid (TXA) in shoulder arthroplasty has grown in popularity due to the perceived benefits of reduction in intra-operative blood loss and the related adverse sequelae. Both intravenous (IV) and oral (PO) formulations of TXA exist and there is minimal data regarding the optimal route of administration. This study aimed to assess whether there was a significant difference in efficacy between the administration of PO vs. IV TXA prior to total shoulder arthroplasty. We hypothesized equivalence in preoperative (preop) to postoperative change in hemoglobin (Hg) and hematocrit (Hct) as well as the length of stay (LOS), 90-day readmission, transfusion rates and adverse events between the two routes. Materials and methodsA single-center retrospective chart review was conducted between May 2022 and January 2023. All patients undergoing primary anatomic or reverse total shoulder arthroplasty during this period were included. Patients undergoing revision shoulder arthroplasty or arthroplasty for fracture were excluded. The primary outcome of interest was the change (Δ) in preop to postoperative day 1 Hg and Hct reported as ΔHg and ΔHct. Intraoperative estimated blood loss (EBL), transfusion rates, patient demographics, LOS, and adverse event data were also collected. ResultsTwo hundred and thirty patients who underwent shoulder arthroplasty met the inclusion criteria. A total of 176 patients received preoppreop IV TXA and 54 patients received preop PO TXA. There was no significant difference between groups in the mean ΔHg (1.69 in the IV group and 2.52 in the PO group, P = .11) or ΔHct (5.19 in the IV group and 5.04 in the PO group, P = .42). There was no significant difference in LOS, transfusion rates, or 90-day readmission between groups. There was a significant difference in the mean EBL between the two groups (123.78cc in the IV group and 173.06cc in the PO group, P < .001). Our study was adequately powered at 0.95. ConclusionThere was no statistically significant difference between the IV and PO TXA groups when comparing preop to postoperative day 1 change in Hg and Hct, LOS, transfusion rates, surgical site infections, and 90-day readmission indicating similar efficacy between the two routes of administration. EBL was found to be significantly higher in the PO TXA group, though the clinical significance of this finding is indeterminate. Given these findings, however, PO TXA may be a reliable alternative to IV TXA in primary shoulder arthroplasty.