Intraoperative Blood Transfusion Requirements Research Articles

Deep Inferior Epigastric Perforator Flap (D.I.E.P) for Breast Reconstruction: Impact of Intraoperative Intrathecal Morphine on Outcome

Background: Pain control after breast reconstruction with Deep Inferior Epigastric Perforator (DIEP) often requires intravenous narcotic analgesia and inpatient hospitalization. Intrathecal morphine (ITM) administration analgesia is increasing in popularity because it decreases the use of intravenous analgesic medications and offer comparable pain relief with less systemic side effects. Questions/purposes: The aim of this retrospective study was to evaluate the effect of intrathecal morphine on postoperative morbidity of breast reconstruction by Deep Inferior Epigastric Perforator flap and compare it with intravenous narcotic analgesia. Methods: 269 patients underwent immediate or delayed DIEP reconstruction after mastectomy, by the same surgeon, at Jules Bordet Institute. Patients receiving ITM analgesia (300 μ) were matched 1:3 with patients undergoing intravenous narcotic analgesia for pain control in the same years by the same surgeon. Differences in peri- and postoperative complications across the two groups were assessed. Results: The two groups were comparable in terms of demographic characteristics and factors of morbidity. Intraoperative variables were not statistically different between the groups except for intraoperative blood loss (P = 0.0001), transfusion (P = 0.0001) and Intraoperative liquid requirement (p = 0.0001). Intra and postoperative blood pressure were lower in ITM group (p < 0.05). Patients in ITM group showed lower postoperative analgesia requirement (P < 0,0001), less respiratory complications and less acute respiratory failure (P = 0,003 and P = 0,004, respectively). No statistically significant differences in the length of hospital stay (LOS) were noted Conclusion: We found that intrathecal morphine analgesia was associated with less blood loss and fluid administration, better postoperative pain control, and less respiratory complications with an acceptable security profile than intravenous narcotic analgesia. Clinical relevance: This study suggests that using intrathecal morphine may result in less blood loss and blood transfusion, better postoperative pain control, and less respiratory complications.

The Impact of Preoperative Variables on Intraoperative Blood Loss and Transfusion Requirements During Orthotopic Liver Transplant.

Liver transplant traditionally and potentially is associated with the risk of massive blood loss and transfusion, which can adversely affect transplant outcomes. Many variables influence the amount of bleeding, and these can be categorized as patient related, surgery related, and graft related. We aimed to assess the effects of these variables on the amount of bleeding and transfusion during liver transplant; predicting the risk of massive blood loss can help transplant teams to select and manage patients more effectively. We retrospectively studied 754 patients who underwent liver transplant from 2013 to 2016 and analyzed more than 20 variables that could influence the volume of blood loss and packed cell transfusion. We found that at least 4 variables are strongly and independently correlated with blood loss volume: age, Model for End-Stage Liver Disease score, warm ischemia time, and total bilirubin. Furthermore, intraoperative blood loss had a weak but clinically important correlation with the underlying disease (ie, the cause of liver cirrhosis). Some variables, including international normalized ratio, platelet count, albumin, serum urea nitrogen, creatinine level, sodium level, and the amount of ascites, could be considered as 'dependent' and weak predictors of massive blood loss. Sex of patient, cold ischemia time, surgery technique, and history of previous abdominal surgery were not correlated with the amount of bleeding. With the use of the variables identified, we can properly select patients and surgical teams and promptly use modalities for decreasing and managing blood loss.

Anesthetic Techniques in Octogenarians and Older Undergoing Orthopedic Surgery for Hip Fracture

Objectives: Hip fracture is common orthopedic problems for patients aged 80 years and older. Because of their decreased cardiopulmonary capacity, an optimal anesthetic technique should be chosen by anesthesiologists. The purpose of the present study is to analyze anesthetic techniques and related postoperative mortality in octogenarians and older who underwent hip fractures surgery. Patients and Methods: We analyzed hip fracture surgeries and identified patients aged 80 years and older between January 2012 and December 2013. Patient age, gender, coexisting diseases, American Society of Anesthesiologists (ASA) Physical Status classification, anesthetic technique, hematocrit, hemoglobin, total lymphocyte count (TLC), the length of surgery, intraoperative blood transfusion requirements, postoperative discharge ward, the length of postoperative hospital stay, and postoperative status were recorded. Results: We retrospectively identified 106 patients aged 80 years and older underwent hip fracture surgeries. Six (5.6%), 36 (34.0%), 2 (1.9%), 53 (50.0%), and 9 (8.5%) of procedures were performed under general anesthesia (GA), spinal anesthesia (SA), epidural anesthesia, combined spinal-epidural anesthesia (CSEA), and peripheral nerve block (PNB), respectively. The postoperative 7 and 30-day mortality were 6.6% and 10.4%, respectively. Age, gender, ASA, hematocrit, hemoglobin, TLC, discharge to the ward, the length of postoperative hospital stay, and the postoperative mortality rates were similar between the GA, SA, CSEA, and PNB. There was no relationship between postoperative mortality and anesthetic technique. Conclusion: In octogenarians and older, the postoperative mortality is higher after hip fracture and is not associated with the anesthetic technique.

Postoperative Hematoma Requiring Recraniotomy in 1149 Consecutive Patients With Intracranial Tumors.

The reported 30-day mortality rate after brain tumor surgery is 2.2% to 2.9%, with a postoperative hematoma (POH) as the most frequent cause of death. To investigate the risk factors for a POH requiring a recraniotomy after brain tumor surgery in a large, contemporary, single-institution consecutive series. We included 1149 patients who underwent surgery for intracranial tumors at the Tokushima University Hospital from 1997 to 2014. The patient charts were retrospectively studied from our prospectively collected database. We analyzed the risk factors, type of hemorrhage, time to reoperation, and outcomes. The incidence of a POH requiring a recraniotomy was 2.09%. Among the patients with a POH requiring a recraniotomy, 12.5% died within 30 days of the first surgery. The incidence of a POH requiring a recraniotomy significantly correlated with the incidence of a hemangioblastoma, infratentorial tumors, and a prolonged operative time (>10 h), but not with the patient age or sex, surgical procedure (biopsy or craniotomy), surgical type (primary or secondary), bleeding volume, or intraoperative blood transfusion requirement. A recraniotomy for a POH was performed in 54% of the patients just after the first operation, and within 24 h for 79% of the patients. The clinical status at the time of discharge deteriorated in 52% of the patients. Hemangioblastomas, infratentorial tumors, and an operative time exceeding 10 h were significantly correlated with an increased risk of a POH; these factors were responsible for 12.5% of the 30-day surgical mortality rate.

Effect of tranexamic acid on intraoperative blood loss and transfusion requirements in patients undergoing excision of intracranial meningioma

Surgical excision of meningioma is often complicated by significant blood loss requiring blood transfusion with its attendant risks. Although tranexamic acid is used to reduce perioperative blood loss, its blood conservation effect is uncertain in neurosurgery. Sixty adults undergoing elective craniotomy for meningioma excision were randomized to receive either tranexamic acid or placebo, initiated prior to skin incision. Patients in the tranexamic acid group received intravenous bolus of 20mg/kg over 20min followed by an infusion of 1mg/kg/h till the conclusion of surgery. Intraoperative blood loss, transfusion requirements and estimation of surgical hemostasis using a 5-grade scale were noted. Postoperatively, the extent of tumor excision on CT scan and complications were observed. Demographics, tumor characteristics, amount of fluid infusion, and duration of surgery and anesthesia were comparable between the two groups. The amount of blood loss was significantly less in tranexamic acid group compared to placebo (830mlvs 1124ml; p=0.03). The transfusion requirement was less in tranexamic acid group (p>0.05). The patients in tranexamic acid group fared better on a 5-grade surgical hemostasis scale with more patients showing good hemostasis (p=0.007). There were no significant differences between the groups with regards to extent of tumor removal, perioperative complications, hospital stay or neurologic outcome. To conclude, administration of tranexamic acid significantly reduced blood loss in patients undergoing excision of meningioma. Fewer patients in the tranexamic acid group received blood transfusions. Surgical field hemostasis was better achieved in patients who received tranexamic acid.

Thrombocytopenia in cirrhosis: Impact of fibrinogen on bleeding risk

AIMTo investigate the relationship between baseline platelet count, clauss fibrinogen, maximum amplitude (MA) on thromboelastography, and blood loss in orthotopic liver transplantation (OLT).METHODSA retrospective analysis of our OLT Database (2006-2015) was performed. Baseline haematological indices and intraoperative blood transfusion requirements, as a combination of cell salvage return and estimation of 300 mls/unit of allogenic blood, was noted as a surrogate for intraoperative bleeding. Two groups: Excessive transfusion (> 1200 mL returned) and No excessive transfusion (< 1200 mL returned) were analysed. All data analyses were conducted using IBM SPSS Statistics version 23.RESULTSOf 322 OLT patients, 77 were excluded due to fulminant disease; redo transplant or baseline haemoglobin (Hb) of < 80 g/L. One hundred and fourteen (46.3%) were classified into the excessive transfusion group, 132 (53.7%) in the no excessive transfusion group. Mean age and gender distribution were similar in both groups. Baseline Hb (P ≤ 0.001), platelet count (P = 0.005), clauss fibrinogen (P = 0.004) and heparinase MA (P = 0.001) were all statistically significantly different. Univariate logistic regression with a cut-off of platelets < 50 × 109/L as the predictor and Haemorrhage as the outcome showed an odds ratio of 1.393 (95%CI: 0.758-2.563; P = 0.286). Review of receiver operating characteristic curves showed an area under the curve (AUC) for platelet count of 0.604 (95%CI: 0.534-0.675; P = 0.005) as compared with AUC for fibrinogen level, 0.678 (95%CI: 0.612-0.744; P ≤ 0.001). A multivariate logistic regression shows United Kingdom model for End Stage Liver Disease (P = 0.006), Hb (P = 0.022) and Fibrinogen (P = 0.026) to be statistically significant, whereas Platelet count was not statistically significant.CONCLUSIONPlatelet count alone does not predict excessive transfusion. Additional investigations, e.g., clauss fibrinogen and viscoelastic tests, provide more robust assessment of bleeding-risk in thrombocytopenia and cirrhosis.

Risk factors for intraoperative massive transfusion in pediatric liver transplantation: a multivariate analysis.

Background: Pediatric liver transplantation (LT) is strongly associated with increased intraoperative blood transfusion requirement and postoperative morbidity and mortality. In the present study, we aimed to assess the risk factors associated with massive transfusion in pediatric LT, and examined the effect of massive transfusion on the postoperative outcomes.Methods: We enrolled pediatric patients who underwent LT between December 1994 and June 2015. Massive transfusion was defined as the administration of red blood cells ≥100% of the total blood volume during LT. The cases of pediatric LT were assigned to the massive transfusion or no-massive transfusion (administration of red blood cells <100% of the total blood volume during LT) group. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with massive transfusion in pediatric LT. Kaplan-Meier survival analysis, with the log rank test, was used to compare graft and patient survival within 6 months after pediatric LT between the 2 groups.Results: The total number of LT was 112 (45.0%) and 137 (55.0%) in the no-massive transfusion and massive transfusion groups, respectively. Multivariate logistic regression analysis indicated that high white blood cell (WBC) count, low platelet count, and cadaveric donors were significant predictive factors of massive transfusion during pediatric LT. The graft failure rate within 6 months in the massive transfusion group tended to be higher than that in the no-massive transfusion group (6.6% vs. 1.8%, P = 0.068). However, the patient mortality rate within 6 months did not differ significantly between the massive transfusion and no-massive transfusion groups (7.3% vs. 7.1%, P = 0.964).Conclusion: Massive transfusion during pediatric LT is significantly associated with a high WBC count, low platelet count, and cadaveric donor. This finding can provide a better understanding of perioperative blood transfusion management in pediatric LT recipients.

Liver parenchymal transection techniques

While liver surgery has become safer with improvements in peri-operative management, parenchymal resection is the part of the procedure which is associated with major loss of blood and damage to important structures if not performed carefully. The ideal technique for hepatic parenchymal transection should be quick, easy to perform, reduce intra-operative blood loss and transfusion requirement, reduce post-operative bile leakage, and cause minimal damage to the surrounding hepatic parenchyma-- preferably at the lowest cost possible. This paper is a review of commonly used techniques for liver parenchymal transection during liver resections. According to the literature, there is little benefit of using the complicated and expensive devices over the simpler clamp crushing technique. We in our institution, who perform a large number of liver resections and living donor transplants, prefer to use the clamp crushing technique with a bipolar cautery for most resections and cavitron ultrasonic aspirator(CUSA) with a bipolar cautery for removal of part of the liver from a living donor.

The cost of Pancreatoduodenectomy – An analysis of clinical determinants

BackgroundHealth care spending is increasing the world over. Determining preventable or correctable factors may offer us valuable insights into developing strategies aimed at reducing costs and improving patient care. The aim of this study was to conduct an exploratory analysis of clinical factors influencing costs of Pancreatoduodenectomy (PD). MethodsThe financial and clinical records of 173 consecutive patients who underwent PD at a tertiary care referral centre, between January 2013 and June 2015 were analysed. ResultsComplications, by themselves, did not increase costs associated with PD unless they resulted in an increase in the duration of stay more than 11 days. Intraoperative blood transfusion (p-.098) and performance of an end-to-side PJ (p-.043) were independent factors significantly affecting costs. Synchronous venous resections significantly increased costs (p-.006) without affecting duration of stay. Advancing age, hypertension, neurological and respiratory disorders, preoperative endoscopic retrograde cholangiopancreatography (ERCP), performance of a feeding jejunostomy, and surgical complications eg PPH, POPF and DGE significantly increased the duration of stay sufficient enough to influence costs of PD. ConclusionsIt is not the merely the development, but severity of complications that significantly increase the cost of PD by increasing hospital stay. Strategies aimed at reducing intraoperative blood transfusion requirement as well as minimising the development of POPF can help reduce costs. Synchronous venous resections significantly increase costs independent of hospital stay. This study identified nine factors that may be included in the development of a preoperative nomogram that could be used in preoperative financial counselling of patients undergoing PD.

Blood Loss and Transfusion Requirements in Metastatic Spinal Tumor Surgery: Evaluation of Influencing Factors.

Metastatic spine tumor surgery (MSTS) can be associated with significant blood loss. Previous studies did not provide comprehensive data on blood loss in MSTS. Thorough study elaborating the blood loss, transfusion requirement, and their influencing factors is required. This study aimed to investigate the estimated blood loss and transfusion requirements associated with various surgical approaches and surgically managed vertebral levels for spinal metastases from different primary tumors. The study retrospectively evaluated 243 patients who underwent surgery for metastatic spine tumors at the authors' institution between 2005 and 2014. Estimated intraoperative blood loss and transfusion requirement were assessed for different primary tumors including lung, breast, prostate, gastrointestinal, renal, liver, thyroid, myeloma/lymphoma, and others; types of surgical procedure (cervical corpectomy±stabilization, thoracolumbar posterior decompression±instrumentation, thoracolumbar corpectomy, minimally invasive surgery); and levels of instrumentation and decompression. Multivariate linear regression was attempted to investigate the factors influencing blood loss and transfusion requirements. The mean blood loss was 870±720ml, and the average blood transfusion was 1.5±1.9 U. The mean blood loss was 1103ml for patients who received blood transfusion and 597ml for those who did not. Multivariate analysis showed that the significant factors influencing blood loss were primary tumor, type of surgery, and prolonged operative time. The influencing factors for blood transfusion were primary tumor, type of surgery, preoperative hemoglobin, and prolonged operative time. Significant variations in blood loss and transfusion requirement were based on primary tumor of spinal metastases, surgical approaches, and operative time. These findings will help clinicians in preoperative planning to address the problem of blood loss during MSTS.

Is it necessary to embolise all spinal metastases from primary renal tumours?

IntroductionSpinal metastases secondary to renal cell carcinoma are associated with significant intra-operative blood loss. Our aim was to assess if embolisation reduced the intra-operative blood loss and transfusion requirement. MethodsWe performed a retrospective cohort study of 25 patients undergoing surgery between 2003 and 2011. Results14 underwent pre-operative embolisation; 11 did not. There was no significant difference in intra-operative blood loss, 1336ml vs 1492ml in the non-embolised (p value=0.116). 43% of embolised patients required an intra operative blood transfusion vs 27% in the non-embolised. ConclusionOur results suggest that not all patients with spinal metastatic renal carcinoma require pre-operative embolisation.

Effects of Continuous Octreotide Infusion on Intraoperative Transfusion Requirements During Orthotopic Liver Transplantation

Orthotopic liver transplantation (OLT) is often associated with major hemorrhage and a large red blood cell (RBC) transfusion requirement. Massive transfusion during OLT has been associated with decreased patient and graft survival. As a result, the anesthesiologist may use various techniques to decrease intraoperative blood loss and transfusion requirements, including maintenance of a low central venous pressure, antifibrinolytic drugs, cell salvage, and vasopressors. Due to its properties of splanchnic vasoconstriction and resultant decrease in portal venous blood flow, octreotide may decrease blood loss during the preanhepatic phase of OLT. We performed a retrospective review of 50 consecutive liver transplantations; a continuous octreotide infusion was used during the preanhepatic phase in 30 of these cases. We hypothesized that intraoperative transfusion requirements would be reduced in those patients treated with octreotide. Statistical analysis found that the number of RBCs transfused decreased from 20.4 U to 18.1 U when octreotide was used, although this result was not statistically significant (P = .5). Additional analysis found a significant positive correlation between the number of RBCs transfused and total operating room (OR) time, preoperative international normalized ratio (INR), and model for end-stage liver disease (MELD) and a negative correlation between the number of RBCs transfused and preoperative platelets and hemoglobin. Although our small study did not show a statistical difference in the number of units transfused, there was an absolute difference. A prospective, randomized trial would be useful in elucidating the true effect of octreotide on RBC transfusion requirements during OLT.

Prospective, Randomized Trial to Evaluate Efficacy of a Bipolar Sealer in Direct Anterior Approach Total Hip Arthroplasty

Total hip arthroplasty can be associated with substantial blood loss requiring allogenic transfusions. Intraoperative blood loss patterns in DAA differ from other approaches. This study evaluated the hemostatic efficacy of a bipolar sealer in DAA THA on surgical blood loss and transfusion requirements. 118 patients were enrolled in this prospective, randomized, double-blinded trial. Primary outcome measure was transfusion rate, while secondary measures included calculated blood loss. A lower transfusion rate was found in the treatment group (3.5 % vs 16.4%, P=.03). There were differences in Hemoglobin-drop (P=.04), calculated blood loss (P=.02), and hidden blood loss (P=.02), favoring the treatment group. The use of a bipolar sealer decreased intraoperative blood loss and transfusion requirements in the study population.

Influence of curve magnitude and other variables on operative time, blood loss and transfusion requirements in adolescent idiopathic scoliosis.

Posterior spinal instrumentation and fusion for correction of adolescent idiopathic scoliosis (AIS) typically requires lengthy operating time and may be associated with significant blood loss and subsequent transfusion. This study aimed to identify factors predictive of duration of surgery, intraoperative blood loss and transfusion requirements in an Irish AIS cohort. A retrospective review of 77 consecutive patients with AIS who underwent single-stage posterior spinal instrumentation and fusion over a two-year period at two Dublin tertiary hospitals was performed. Data were collected prospectively and parameters under analysis included pre- and postoperative radiographic measurements, intraoperative blood loss, surgical duration, blood products required, laboratory blood values and perioperative complications. Mean preoperative primary curve Cobb angle was 62.3°; mean surgical duration was 5.6h. The perioperative allogeneic red blood cell transfusion rate was 42.8% with a median requirement of 1 unit. Larger curve magnitudes were positively correlated with longer fusion segments, increased operative time and greater estimated intraoperative blood loss. Preoperative Cobb angles greater than 70° [Relative Risk (RR) 4.42, p=0.003] and estimated intraoperative blood loss greater than 1400ml (RR 3.01, p=0.037) were independent predictors of red blood cell transfusion risk. Larger preoperative curve magnitudes in AIS increase operative time and intraoperative blood loss; preoperative Cobb angles greater than 70(o) and intraoperative blood loss greater than 1400ml are predictive of red blood cell transfusion requirement in this patient group.

Conservative Management of Invasive Placenta Using Combined Prophylactic Internal Iliac Artery Balloon Occlusion and Immediate Postoperative Uterine Artery Embolization

PurposeThe objective of the study was to evaluate the efficacy and safety of combined prophylactic intraoperative internal iliac artery balloon occlusion and postoperative uterine artery embolization in the conservative management (uterine preservation) of women with invasive placenta undergoing scheduled caesarean delivery. MethodsTen women (mean age 35 years) with invasive placenta choosing caesarean delivery without hysterectomy had preoperative insertion of internal iliac artery occlusion balloons, intraoperative inflation of the balloons, and immediate postoperative uterine artery embolization with absorbable gelatin sponge. A retrospective review was performed with institutional review board approval. Outcome measures were intraoperative blood loss, transfusion requirement, hysterectomy rate, endovascular complications, surgical complications, and postoperative morbidity. ResultsAll women had placenta increta or percreta, and concomitant complete placenta previa. Mean gestational age at delivery was 36 weeks. In 6 women the placenta was left undisturbed in the uterus, 2 had partial removal of the placenta, and 2 had piecemeal removal of the whole placenta. Mean estimated blood loss during caesarean delivery was 1.2 L. Only 2 patients (20%) required blood transfusion. There were no intraoperative surgical complications, endovascular complications, maternal deaths, or perinatal deaths. Three women developed postpartum complications necessitating postpartum hysterectomy; the hysterectomy rate was therefore 30% and uterine preservation was successful in 70%. ConclusionCombined bilateral internal iliac artery balloon occlusion and uterine artery embolization may be an effective strategy to control intraoperative blood loss and preserve the uterus in patients with invasive placenta undergoing caesarean delivery.

Preoperative Thromboelastometry as a Predictor of Transfusion Requirements during Adult Living Donor Liver Transplantation

Background: The ability to predict transfusion requirements may improve perioperative bleeding management as an integral part of a patient blood management program. Therefore, the aim of our study was to evaluate preoperative thromboelastometry as a predictor of transfusion requirements for adult living donor liver transplant recipients. Methods: The correlation between preoperative thromboelastometry variables in 100 adult living donor liver transplant recipients and intraoperative blood transfusion requirements was examined by univariate and multivariate linear regression analysis. Thresholds of thromboelastometric parameters for prediction of packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate transfusion requirements were determined with receiver operating characteristics analysis. The attending anesthetists were blinded to the preoperative thromboelastometric analysis. However, a thromboelastometry-guided transfusion algorithm with predefined trigger values was used intraoperatively. The transfusion triggers in this algorithm did not change during the study period. Results: Univariate analysis confirmed significant correlations between PRBCs, FFP, platelets or cryoprecipitate transfusion requirements and most thromboelastometric variables. Backward stepwise logistic regression indicated that EXTEM coagulation time (CT), maximum clot firmness (MCF) and INTEM CT, clot formation time (CFT) and MCF are independent predictors for PRBC transfusion. EXTEM CT, CFT and FIBTEM MCF are independent predictors for FFP transfusion. Only EXTEM and INTEM MCF were independent predictors of platelet transfusion. EXTEM CFT and MCF, INTEM CT, CFT and MCF as well as FIBTEM MCF are independent predictors for cryoprecipitate transfusion. Thromboelastometry-based regression equation accounted for 63% of PRBC, 83% of FFP, 61% of cryoprecipitate, and 44% of platelet transfusion requirements. Conclusion: Preoperative thromboelastometric analysis is helpful to predict transfusion requirements in adult living donor liver transplant recipients. This may allow for better preparation and less cross-matching prior to surgery. The findings of our study need to be re-validated in a second prospective patient population.

Blood Type O is not associated with increased blood loss in extensive spine surgery

Study ObjectiveTo investigate whether Type O blood group status is associated with increased intraoperative blood loss and requirement of blood transfusion in extensive spine surgery. DesignRetrospective comparative study. SettingUniversity-affiliated, non-profit teaching hospital. MeasurementsData from 1,050 ASA physical status 1, 2, 3, 4, and 5 patients who underwent spine surgeries involving 4 or more vertebral levels were analyzed. Patients with Type O blood were matched to similar patients with other blood types using propensity scores, which were estimated via demographic and morphometric data, medical history variables, and extent of surgery. Intraoperative estimated blood loss (EBL) was compared among matched patients using a linear regression model; intraoperative transfusion requirement in volume of red blood cells, fresh frozen plasma, platelet, cryoprecipitate, cell salvaged blood, volume of intraoperative infusion of hetastarch, 5% albumin, crystalloids, and hospital length of hospital (LOS) were compared using Wilcoxon rank-sum tests. Main ResultsIntraoperative EBL and requirement of blood product transfusion were similar in patients with Type O blood group and those with other blood groups. ConclusionThere was no association between Type O blood and increased intraoperative blood loss or blood transfusion requirement during extensive spine surgery, with similar hospital LOS in Type O and non-O patients.

Inferior mesenteric vein serves as an alternative guide for transection of the pancreatic body during pancreaticoduodenectomy with concomitant vascular resection: a comparative study evaluating perioperative outcomes.

BackgroundTumors of the pancreatic head often involve the superior mesenteric and portal veins. The purpose of this study was to assess perioperative outcomes after pancreaticoduodenectomy (PD) with concomitant vascular resection using the inferior mesenteric vein (IMV) as a guide for transection of the pancreatic body (Whipple at IMV, WATIMV).MethodsOne hundred thirty-seven patients had segmental vein resection during PD between January 2006 and June 2013. Depending on whether the standard approach of creating a tunnel anterior to the mesenterico-portal vein (MPV) axis was achieved for pancreatic transection, patients were subjected to a standard PD with vein resection procedure (s-PD + VR, n = 75) or a modified procedure (m-PD + VR, n = 62). Within the m-PD + VR group, 28 patients underwent the WATIMV procedure, while 34 patients underwent the usual procedure of transection, or ‘central pancreatectomy’ (c-PD + VR).ResultsThe volume of intraoperative blood loss and the blood transfusion requirements were significantly greater, and the venous wall invasion and neural invasion frequency were significantly higher in the m-PD + VR group compared with the s-PD + VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, and grades of complications between the two groups. Multivariate logistic regression identified intraoperative blood transfusion (P = 0.004) and vascular invasion (P = 0.008) as the predictors of postoperative morbidity. Further stratification of the entire cohort of 62 (45%) patients who underwent m-PD + VR showed a higher rate of negative resection margins (96.4%) in the WATIMV group compared with the c-PD + VR group (76.5%) (P = 0.06). The volume of intraoperative blood loss (P = 0.013), and intraoperative blood transfusion requirements (P = 0.07) were significantly greater in the c-PD + VR group compared with the WATIMV group. Furthermore, high intraoperative blood loss and tumor stage were predictive of a positive resection margin.Conclusions‘Whipple at the IMV (WATIMV)’ has comparable postoperative morbidity with standard PD + VR. If IMV runs into the splenic vein, it could serve as an alternative guide for transection of the pancreatic body during PD + VR.

Initial experience of surgical microwave tissue precoagulation in liver resection for hepatocellular carcinoma in cirrhotic liver.

Surgical hepatic resection has been considered as the first-line treatment which is most effective and radical treatment for HCC, however, HCC is usually associated with poor liver function owing to chronic hepatitis or liver cirrhosis. Techniques that can eradicate the tumor and also preserve liver function are needed. Moreover, hepatic resection, in the presence of cirrhosis, raises special problem of high risk as hemorrhage and liver failure, thus, good clinical results can only be achieved by minimizing operative blood loss, time of the intervention as well as the hepatic reserve. The tremendous progress in microwave technology has recently attracted considerable attention. This study evaluated the feasibility of this new liver transection technique demonstrating the high performance of this procedure, the accuracy in terms of squeeze effect on veins and portal branch and in terms of reducing the intra operative blood loss, and minimizing the operative time for safe hepatectomy. Twenty-six consecutive patients a first-time diagnosis of hepatocellular carcinoma (HCC) on top of liver cirrhosis were recruited for the study, from August 2011 to January 2013. All patients were subjected to full clinical examination, laboratory investigations, abdomen ultrasound (U/S), triphasic computed tomographic liver scan (CT) and dynamic magnetic resonance imaging (MRI) in some doubtful cases. Inclusion requirements were presence of resectable disease without vascular invasion or extrahepatic spread at imaging, Child-Pugh class A & B (Score 7) liver cirrhosis, (INR) < 1.6 or platelet count) 60 000/mm3 with no previous treatment. Patients were treated by applying pre-coagulation of the liver transection lines using microwave probe positioned in parallel to the line of resection by open approach after intra-operative U/S assessment for localization of the tumor and line of resection. The procedures were performed under general anesthesia. Mobilization of the liver was not necessary to be done in all cases. Intra-operative ultrasound (Aloka, Tokyo, Japan) was used to exclude lesions not detected pre-operatively (operative surprise), to define the location, number and size of the tumor and to identify large intra-hepatic large vascular and biliary structures, and guide insertion of the microwave applicator. Intraoperative ultrasound was used again, to assess that the line of resection was done. Primary endpoints documented were total operative time, time for liver parenchyma transection, intraoperative blood loss and blood transfusion requirements. Secondary endpoints included postoperative complications, mortality and intensive care unit (ICU) together with hospital stay.

Reoperative Complications after Primary Orthotopic Liver Transplantation: A Contemporary Single-Center Experience in the Post–Model for End-Stage Liver Disease Era

Data on complications requiring reoperation after orthotopic liver transplantation (OLT) are limited. We sought to describe the spectrum of reoperative complications after OLT, evaluate the associations with graft and patient survival, and identify predictors of need for reoperation. We retrospectively studied adult patients who underwent primary OLT at our institution from February 2002 to July 2012. The primary outcomes included occurrence of a reoperative complication. Secondary outcomes were graft and patient survival. Multivariable logistic regression analysis was used to model the associations of recipient, donor, and operative variables with reoperation. Of 1,620 patients, 470 (29%) had complications requiring reoperation. The most common reoperative complication was bleeding (17.3%). Compared with patients not requiring reoperation, patients with reoperative complications had greater Model for End-Stage Liver Disease scores and need for pretransplantation hospitalization, mechanical ventilation, vasopressors, and renal replacement therapy; considerably longer cold and warm ischemia times and greater intraoperative blood transfusion requirements; and substantially worse 1-, 3-, and 5-year graft and patient survival rates. In multivariable analysis, predictors of reoperative complications included intraoperative transfusion of packed RBCs (odds ratio [OR]= 2.21; 95% CI, 1.91-2.56), donor length of hospitalization >8 days (OR= 1.87; 95% CI, 1.28-2.73), recipient pretransplantation mechanical ventilation (OR= 1.65; 95% CI, 1.21-2.24), cold ischemia time >9 hours (OR= 1.63; 95% CI, 1.23-2.17), warm ischemia time >55 minutes (OR= 1.58; 95% CI, 1.02-2.44), earlier major abdominal surgery (OR= 1.41; 95% CI, 1.03-1.92), and elevated donor serum sodium (OR= 1.17; 95% CI, 1.03-1.31). Patients who require reoperation for complications after OLT have high pretransplantation acuity and inferior post-transplantation survival. We identified factors associated with reoperative complications to guide perioperative donor-recipient matching and improve outcomes.