Lower Transfusion Rate Research Articles

Less transfusion is still more-red blood cell transfusion affects long-term mortality in cardiac surgery.

Previous studies indicated higher long-term mortality after the transfusion of allogeneic red blood cells and newer recommendations emphasize lower transfusion rates. Consequences of transfusion of red blood cells in cardiac surgery are unclear, as later studies focused on transfusion triggers and short-term outcomes and reports on long-term complications after cardiac surgery are few. The mandatory Western Denmark Heart Registry was used to identify all adult cardiac surgeries performed in four centres from 2000-2019. Patients with multiple entries or previous cardiac surgery, special/complex procedures, dying within 30 days and not eligible for follow-up were excluded. A total of 32,581 adult cardiac surgeries performed in four centres from 2000-2019 were included. The Kaplan-Meier survival plot for low-risk patients undergoing simple cardiac surgery showed a significantly lower 15-year survival (0.384 vs 0.661) when receiving perioperative red blood cell transfusion (OR 2.43 (CL 2.23-2.66)). The risk decreased with increasing comorbidity or age, and in high-risk patients, no difference was found. The adjusted risk ratio, after RBC transfusion, including age, sex, comorbidity and surgery, was 1.62 (1.48-1.77). Despite reduced transfusion rates, long-term follow-up on especially low-risk patients undergoing comparable cardiac surgery still demonstrates a substantially higher mortality in patients receiving perioperative red blood cell transfusion. Even transfusion of 1-2 units is associated with increased long-term mortality.

General versus spinal anesthesia in percutaneous nephrolithotomy: A systematic review and meta-analysis

Background: Percutaneous nephrolithotomy (PCNL) is the preferred treatment for the removal of large kidney stones, sized >20 mm. However, there is still an ongoing debate concerning the best anesthesia for PCNL. This study aimed to compare the efficacy and safety between general and spinal anesthesia for PCNL. Methods: A systematic review and meta-analysis study. A systematic, electronic literature search was performed in several databases, including PubMed, Scopus, and Google Scholar until July 1st, 2022. The quality of the articles was examined using Crombie's Items (for non-randomized controlled trials (RCTs)) and Jadad Scale (for RCTs). The outcomes assessed were operation time, fluoroscopy time, length of stay, stone-free rate, overall complication rate, specific postoperative complications, cost, pain score, and postoperative analgesic requirement. The article selection was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We assessed four RCTs and eight retrospective studies. Meta-analysis of selected studies was performed using the Review Manager 5.3. Results: General anesthesia resulted in fewer Clavien–Dindo grade II (OR: 0.68; 95% CI: 0.49 – 0.94; p=0.02), major complications (OR: 0.65; 95% CI: 0.45 – 0.94; p=0.02, and lower transfusion rates (OR: 0.70; 95% CI: 0.53 – 0.94; p=0.02). Whereas spinal anesthesia resulted in faster operation time (Mean Difference: -12.98; 95% CI: -20.56 – -5.41; p<0.001, fluoroscopy time (MD: -26.15; 95% CI: -42.79 – -9.50; p=0.002), reduced length of stay (MD: -0.47; 95% CI: -0.75 – 0.20; p<0.001), and lower postoperative analgesic requirement and cost. No significant difference in stone-free rate (OR: 1.08; 95% CI: 0.92 – 1.26; p=0.37). PCNL performed using either general anesthesia or spinal anesthesia is equally safe and effective. Conclusions: Each method of anesthesia has its own advantages and disadvantages. The final choice between general and spinal anesthesia should be based on the patient's condition and surgical team preference.

Perioperative, functional, and oncologic outcomes of robot-assisted versus open partial nephrectomy for complex renal tumors (RENAL score ≥ 7): an evidence-based analysis.

This study aims to assess the efficacy and safety of robot-assisted partial nephrectomy (RAPN) compared with open partial nephrectomy (OPN) in the management of complex renal tumors (defined as RENAL score ≥ 7). We conducted a comprehensive literature search in PubMed, Embase, Web of Science, and Cochrane Library to identify relevant comparative studies up to January 2023. This study was conducted with the Review Manager 5.4 software, and included RAPN and OPN-controlled trials for complex renal tumors. The prime outcomes were to assess the perioperative results, complications, renal function, and oncologic outcomes. A total of 1493 patients were included in seven studies. Compared to OPN, RAPN was associated with a significantly shorter hospital stay (weighted mean difference [WMD] - 1.53days, 95% confidence interval [CI] - 2.44, - 0.62; p = 0.001), less blood loss (WMD - 95.88mL, 95% CI - 144.19, - 47.56; p = 0.0001), lower transfusion rates (OR 0.33, 95% CI 0.15, 0.71; p = 0.005), fewer major complications (OR 0.63, 95% CI 0.39, 1.01; p = 0.05), and fewer overall complications (OR 0.49, 95% CI 0.36, 0.65; p < 0.00001). Nevertheless, no statistically significant differences were found between the two groups in operative time, warm ischemia time, estimated glomerular decline, intraoperative complications, positive surgical margins, local recurrence, overall survival, and recurrence-free survival. The study demonstrated that RAPN had superior perioperative parameters and fewer complications when compared to OPN for complex renal tumors. However, no significant differences were found in terms of renal function and oncologic outcomes.

Robot-assisted retroperitoneal lymph node dissection: a systematic review of perioperative outcomes.

To assess the safety and feasibility of robot-assisted retroperitoneal lymph node dissection (R-RPLND) and to compare the perioperative outcomes of R-RPLND with open RPLND (O-RPLND), as RPLND forms an integral part of the management of testis cancer and R-RPLND is a minimally invasive treatment option for this disease. The PubMed® , Scopus® , Cochrane Central Register of Controlled Trials, and Web of Science™ databases were searched for studies reporting perioperative outcomes of primary and post-chemotherapy R-RPLND and studies comparing R-RPLND with O-RPLND. The search yielded 42 articles describing R-RPLND, including five comparative studies. The systematic review included 4222 patients (single-arm studies, n= 459; comparative studies, n= 3763). Of 459 patients in the single-arm studies, 271 underwent primary R-RPLND and 188 underwent post-chemotherapy R-RPLND. For primary R-RPLND, the operative time ranged from 175 to 540 min and the major complication rate was 4.1%. For post-chemotherapy R-RPLND, the operative time ranged from 134 to 550 min and the major complication rate was 8.5%. The conversion rate to open surgery was 2.2% in primary R-RPLND and 9.0% in post-chemotherapy R-RPLND. In comparison with O-RPLND, R-RPLND was associated with a lower transfusion rate (14.5% vs 0.9%, P< 0.001) and a lower complication rate (18.5% vs 7.8%, P= 0.002). Robot-assisted RPLND has acceptable perioperative outcomes in both the primary and post-chemotherapy settings but a notable rate of conversion to open surgery in the post-chemotherapy setting. Compared with O-RPLND, R-RPLND is associated with a lower transfusion rate and fewer overall complications. Given the potential impact of selection bias, the optimal patient selection criteria for R-RPLND remain to be elucidated.

Robotic retroperitoneal lymph node dissection: A systematic review and meta-analysis of perioperative outcomes.

420 Background: Retroperitoneal lymph node dissection (RPLND) forms an integral part of the management of testis cancer. Robotic RPLND (R-RPLND) is a minimally invasive treatment option for this disease. This systematic review assessed the safety and feasibility of R-RPLND and compared the perioperative outcomes of R-RPLND with open RPLND (O-RPLND). Methods: The PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science databases were searched for studies reporting perioperative outcomes of primary and post-chemotherapy R-RPLND and studies comparing R-RPLND with O-RPLND. Results: The search yielded 42 articles describing R-RPLND, including five comparative studies. The systematic review included 4,224 patients (single-arm studies, n=461; comparative studies, n=3,763). Of 461 patients in the single-arm studies, 271 underwent primary R-RPLND and 190 underwent post-chemotherapy R-RPLND. For primary R-RPLND, the operative time ranged from 175-540 minutes and the major complication rate was 3.1%. For post-chemotherapy R-RPLND, the operative time ranged from 134-550 min and the major complication rate was 8.4%. The conversion rate to open surgery was 2.2% in primary R-RPLND and 8.9% in post-chemotherapy R-RPLND. In comparison with O-RPLND, R-RPLND was associated with a lower transfusion rate (14.5% vs 0.9%, p=0.0001) and a lower complication rate (18.5% vs 7.8%, p=0.002; Table). Conclusions: R-RPLND has acceptable perioperative outcomes in both the primary and post-chemotherapy settings but a notable rate of conversion to open surgery in the post-chemotherapy setting. Compared with O-RPLND, R-RPLND is associated with a lower transfusion rate and fewer overall complications. Given the potential impact of selection bias, the optimal patient selection criteria for R-RPLND remain to be elucidated. [Table: see text]

Comparison of Contemporary Surgical Outcomes Between Holmium Laser Enucleation of the Prostate and Robotic-Assisted Simple Prostatectomy.

This study reviews contemporary literature on RASP and HoLEP to evaluate perioperative outcomes, common complications, cost analytics, and future directions of both procedures. RASP is indicated for prostates > 80mL, while HoLEP is size-independent. No notable differences were found in operative time, PSA nadir (surrogate for enucleation volume), re-catheterization rates, or long-term durability. Prolonged incontinence and bladder neck contracture rates are low for both surgeries. Patients experience similar satisfaction outcomes and improvements in uroflowmetry and post-void residual volumes. HoLEP demonstrates shorter hospitalizations, lower transfusion rates, lower costs, and higher rates of same-day discharge. RASP offers a shorter learning curve and lower rates of early postoperative urinary incontinence. HoLEP is a size-independent surgery that offers advantages for patients seeking a minimally invasive procedure with the potential for catheter-free same-day discharge. Future directions with single-port simple prostatectomy may offer parity in same-day discharge, but further research is needed to determine broader feasibility.

Efficacy of immediate postoperative intravenous iron supplementation after staged bilateral total knee arthroplasty

BackgroundApproximately 26% of patients undergoing major orthopedic elective procedures have preoperative anemia. This study aimed to investigate the effect of intravenous (IV) iron supplementation on the hemoglobin (Hb) level after staged bilateral total knee arthroplasty (TKA) in patients with or without preoperative anemia.MethodsWe retrospectively analyzed 418 patients who underwent staged bilateral TKA (1 week interval). The iron group (n = 220) received IV iron isomaltoside immediately after each TKA. The no-iron group (n = 198) was recommended to receive transfusion if postoperative anemia was diagnosed between the first and second TKA. Preoperative anemia was present in 42 (21.2%) and 50 (22.7%) patients in the no-iron and iron groups, respectively. Demographic data, preoperative and postoperative Hb levels, Hb level change (preoperative minus postoperative 6-week Hb level), and blood drainage amount were compared between groups.ResultsThe transfusion rate was lower in the iron group than in the no-iron group (96.5% vs. 58.6%, P < 0.001). Overall, the demographic data, preoperative and postoperative 6-week Hb levels, Hb level change, and blood drainage amount were not significantly different between the two groups. Among patients with preoperative anemia, the iron group showed lower Hb level change (0.6 ± 0.9 vs. 0.1 ± 1.1, P = 0.016).ConclusionPatients with preoperative anemia treated with IV iron showed lower Hb level change than did those without IV iron treatment. Despite the lower transfusion rate, the iron group showed similar postoperative 6-week Hb level and Hb level change to the no-iron group.

Minimally invasive isolated anatomic liver segmentectomy for hepatocellular carcinoma using extrahepatic Glissonian approach: surgical techniques and outcomes

Aim: To standardize surgical techniques for and define the safety, feasibility and oncologic validity of minimally invasive anatomic liver segmentectomy for hepatocellular carcinoma (HCC). Methods: We retrospectively studied perioperative and long-term outcomes of isolated anatomic segmentectomy (IA-Seg) using the extrahepatic Glissonian approach in 157 HCC cases, including 77 open and 80 minimally invasive (59 laparoscopic and 21 robotic) cases. Surgical outcomes were compared between the approaches using propensity score matching (PSM). Results: After matching (46:46), compared with open IA-Seg, minimally invasive IA-Seg was significantly associated with less blood loss (274 vs. 955 g), a lower transfusion rate (21.7% vs. 45.7%), the lower postoperative serum total bilirubin (TB) level (1.5 vs. 2.2 mg/dL) and shorter length of hospital stay (LOS) (17 vs. 27 days), while the latter had a significantly higher rate of Pringle maneuver application (15.2% vs. 2.2%) and a higher aspartate aminotransferase (AST) level (669 vs. 402 IU/L). Additionally, laparoscopic and robotic IA-Seg before and after matching (16:16) had comparable perioperative outcomes. Long-term outcomes after IA-Seg for newly developed HCC in matched cohorts were comparable, either between open and minimally invasive IA-Seg (36:36) or between laparoscopic and robotic IA-Seg (12:12). Conclusion: Although minimally invasive IA-Seg is technically demanding, it could be standardized using the extrahepatic Glissonian approach. This procedure for HCC was safe, feasible and oncologically acceptable, with several perioperative outcomes superior to those in open IA-Seg and with comparable long-term outcomes. By expert hands, the laparoscopic or robotic approach could be a reliable option for IA-Seg in selected HCC patients.

Routine Type and Screens Are Unnecessary in Primary Total Joint Arthroplasty: Follow-up After a Change in Practice

BackgroundRoutine type and screens (T&S) prior to total hip (THA) and total knee arthroplasty (TKA) are common despite low transfusion rates. Our institution implemented a practice change after previously demonstrating a transfusion rate of 1.06%. The purpose of this study is to present the follow-up data 1 year after the practice change of discontinuing routine T&S orders in primary total joint arthroplasty. MethodsA practice change was implemented discontinuing routine T&S orders prior to elective primary total joint arthroplasties. We retrospectively reviewed prospectively collected data on preoperative T&S, hemoglobin values, transfusion rates, bleeding disorders, and anticoagulation status. ResultsA total of 663 patients were included in the study (273 THAs and 390 TKAs). The cumulative transfusion rate was 0.75. No patients received an intraoperative transfusion. Three patients (1.1%) received a postoperative transfusion after THA, and 3 patients (0.5%) received a transfusion after TKA. The mean preoperative hemoglobin in the transfused patients was 12.1 g/dL. Thirteen patients underwent a preoperative T&S (2.0%), and only 2 required transfusion (15.4%). Only 1 patient who required transfusion was on preoperative anticoagulation, and no patients with bleeding disorders required transfusions. Discontinuing routine T&S resulted in an estimated cost savings of $124,325.50. ConclusionsDiscontinuation of routine T&S did not result in any adverse consequences. If required, T&S can safely be performed intraoperatively or postoperatively. Surgeons may consider obtaining a T&S if their preoperative hemoglobin is less than 11-12 g/dL or if significant blood loss is expected in a complex primary total joint arthroplasty.

Safety and Efficacy of the Transaxillary Access for Minimally Invasive Mitral Valve Surgery-A Propensity Matched Competitive Analysis.

Background and Objectives: Transaxillary access is a straightforward “single incision—direct vision” concept, based on a 5 cm skin incision in the right anterior axillary line. It is suitable for aortic, mitral and tricuspid surgery. The present study evaluates the hospital outcomes of the transaxillary access for isolated mitral valve surgery compared with full sternotomy. Patients and Methods: The final study group included 480 patients. A total of 160 consecutive transaxillary patients served as treatment group (MICS-MITRAL). Based on a multivariate logistic regression model including age, sex, body-mass-index, EuroScore II and LVEF, a 1:2 propensity matched control-group (n = 320) was generated out of 980 consecutive sternotomy patients. Redo surgeries, endocarditis or combined procedures were excluded. The mean age was 66.6 ± 10.6 years, 48.6% (n = 234) were female. EuroSCORE II averaged 1.98 ± 1.4%. Results: MICS-MITRAL had longer perfusion (88.7 ± 26.6 min vs. 68.7 ± 32.7 min; p < 0.01) and cross-clamp (64.4 ± 22.3 min vs. 49.7 ± 22.4 min; p < 0.01) times. This did not translate into longer procedure times (132 ± 31 min vs. 131 ± 46 min; p = 0.76). Both groups showed low rates of failed repair (MICS-MITRAL: n = 6/160; 3.75%; Sternotomy: n = 10/320; 3.1%; p = 0.31). MICS-MITRAL had lower transfusion rates (p ≤ 0.001), less re-exploration for bleeding (p = 0.04), shorter ventilation times (p = 0.02), shorter ICU-stay (p = 0.05), less postoperative hemofiltration (p < 0.01) compared to sternotomy patients. No difference was seen in the incidence of stroke (p = 0.47) and postoperative delirium (p = 0.89). Hospital mortality was significantly lower in MICS-MITRAL patients (0.0% vs. 3.4%; p = 0.02). Conclusions: The transaxillary access for MICS-MITRAL provides superior cosmetics and excellent clinical outcomes. It can be performed at least as safely and in the same time frame as conventional mitral surgery by sternotomy.

Before-and-After Study of the First Four Years of the Enhanced Recovery after Surgery (ERAS®) Programme in Older Adults Undergoing Elective Colorectal Cancer Surgery.

The aim of this study was to determine whether the inclusion of older patients undergoing elective colorectal cancer resection in the Enhanced Recovery After Surgery (ERAS®) programme could improve clinical outcomes during hospital admission. A before-and-after study in ≥70-year-old patients electively admitted for colorectal cancer resection was designed. In total, 213 patients were included in the ERAS® group, and 158 were included in the control group. The average age was 77.9 years old (SD 5.31) and 57.14% of them were men, with a Charlson Index score of 3.42 (SD 3.32). The ERAS® group presented a lower transfusion rate of 42 (19.7%), compared to 75 (47.5%) in the control group (p &lt; 0.001). The crude odds ratio (OR) for transfusion was 0.27 (95% CI 0.17-0.43; p &lt; 0.001), and the adjusted odds ratio was 0.26 (95% CI 0.14-0.48; p &lt; 0.001). The ERAS® group had a lower percentage of patients with moderate-severe malnutrition on admission, at 23.4% (37 patients) against 36.2% in the control group (42 patients) (p = 0.023), with an OR of 0.47 (95% CI 0.29-0.75; p &lt; 0.002) and an adjusted OR of 0.48 (95% CI 0.29-0.78; p = 0.003). The number of patients who required admission to the intensive care unit (ICU) was also markedly lower: 54 from the ERAS® group (25.4%) versus 71 from the control group (44.9%) (p &lt; 0.001). The inclusion of ≥70-year-old adults in the ERAS® programme resulted in a decrease in transfusions, number of erythrocyte concentrates transfused, and number of ICU admissions, along with improved nutritional status.

Personalized Surgical Transfusion Risk Prediction: Comment.

We have read the study titled “Personalized Surgical Transfusion Risk Prediction Using Machine Learning to Guide Preoperative Type and Screen Orders” by Lou et al.1 and the accompanying editorial titled “Moving from ‘Surgeries’ to Patients: Progress and Pitfalls While Using Machine Learning to Personalize Transfusion Prediction” by Mathis et al. 2 The authors include 4 million surgical cases during a 3-yr period from the American College of Surgeons National Surgical Quality Improvement Program database. The authors used the American College of Surgeons National Surgical Quality Improvement Program database to develop a machine learning model that incorporates patient- and surgery-specific variables to predict transfusion risk and the associated need for preoperative type and screen. The authors hypothesize that their machine learning algorithm would outperform the traditional approach of relying primarily on historical surgery-specific transfusion rates and thus optimize resource allocation by decreasing blood bank waste. The machine learning algorithm recommends fewer preoperative type and screen orders.The study presents in exceptional detail the methodologic approach to developing highly accurate algorithms to predict transfusion risk. Several authors have shown that race is an independent predictor of postoperative transfusion across surgical disciplines, associated with either higher or lower rates of transfusion.3,4 However, the work by Lou et al. did not include any mention of race or ethnicity. Experience from previous algorithms used to model resource allocation in health care demonstrate that omitting this information may lead to perpetuating bias that unfortunately exists within the United States healthcare system.5,6 Although the intent from healthcare providers is to provide the best possible care to their patients, determinants of health are closely linked to race and ethnicity and availability of resources in the United States. Therefore, artificial intelligence models aiming to personalize medicine can present pitfalls for those already with low resource availability, unwittingly withholding care in marginalized communities.5 On the other hand, it has been shown that including race or ethnicity in machine learning models may perpetuate bias, and therefore including race and ethnicity in artificial intelligence remains intensely debated.7,8Our primary question is the following: Why did the authors choose not to include race and ethnicity in their table 1 or in their prediction model? Was the absence of any demographic data in the Lou et al. article an intended or inadvertent omission? Given the potential impact of a patient’s race or ethnicity on clinician decision-making, and the ongoing controversy about the use of these variables in clinical prediction models,8 we believe that an explanation for the absence of this data would be helpful. Inclusion of ethnic and racial minorities in research is important, and transparency is key in the design of prediction models to improve societal health.Dr. Cannesson has funding from Masimo (Irvine, California), Edwards Lifesciences (Irvine, California), and the National Institutes of Health (Bethesda, Maryland) for unrelated work and is a shareholder of Sironis (Newport Beach, California) and Perceptive Medical (Newport Beach, California). The other authors declare no competing interests.

Role of Early Extubation in Decreasing Morbidity and Mortality in Liver Transplantation

BackgroundEarly extubation is a fundamental element integrated into enhanced recovery protocols in orthotopic liver transplantation (OLT). The aim is to evaluate whether early extubation influences short- and medium-term postoperative morbidity and mortality. MethodsA cohort of 209 patients who underwent OLT in a tertiary hospital in a period from January 2016 to December 2018 were retrospectively analyzed. Patients were divided into 2 groups: group 1: early extubation in the intensive care unit and group 2: delayed extubation. Mortality is compared between both groups in the first month and first and third year. Postoperative morbidity was also compared. ResultsPatients in group 1 (n = 165, 79.9%) presented, with statistical significance, lower mortality at 1 month, 1 year, and 3 years; shorter duration of admission to the critical care unit and of hospital stay; lower incidence of surgical reoperation and retransplant; lower rate of transfusion of blood products; fewer pulmonary, digestive, neurologic, cardiologic, hemodynamic, kidney, surgical, infectious, metabolic, thrombotic, vascular, and graft complications; less need for kidney replacement therapy; less refractory ascites; and greater infectious risk. However, no statistically significant differences were found in the need for hospital readmission; in biliary, endocrine, nutritional, hematologic, thrombotic, and hematologic complications; or in graft rejection.In group 1, 6.6% of patients required reintubation. In group 2, 97% of patients could be extubated during the first week; 7.8% required noninvasive mechanical ventilation type bilevel positive airway pressure and 8.1% high flow. Only 2.8% of patients required tracheotomy. ConclusionsThe role of early extubation seems key to improve outcomes in OLT because it reduces the incidence of multiple complications and mortality, with low reintubation rates. It is a feasible and safe procedure.

Thoracoscopic trans-mitral myectomy for hypertrophic obstructive cardiomyopathy: a retrospective single-centre study.

Transaortic myectomy is a common procedure for patients with hypertrophic obstructive cardiomyopathy. Thoracoscopic trans-mitral myectomy has been described in a few small-sample studies and has been recommended as preferable. We herein report our clinical outcomes using the thoracoscopic trans-mitral approach with 76 patients. This is a retrospective single-centre analysis of the safety and efficacy of thoracoscopic trans-mitral myectomy by comparing the clinical outcomes with that of transaortic myectomy. Between April 2019 and October 2021, 132 patients underwent either a transaortic (n = 56) or a thoracoscopic trans-mitral myectomy (n = 76). Compared with those in the transaortic group, patients in the trans-mitral group were more likely to be weaned off the ventilator within 24 h after surgery (80.3% vs 60.7%, P < 0.05) and to require a shorter duration of ventilation [29.01 (43.91) vs 51.12 (94.96) h, P = 0.08] and lower transfusion rate (26.3% vs 48.2%, P < 0.05). The in-hospital mortality rate of the transaortic and trans-mitral groups was 3.6% (n = 2) and 1.3% (n = 1), respectively. No significant inter-group differences were observed regarding in-hospital mortality, the incidence of low cardiac output syndrome or permanent pacemaker implantations. In the trans-mitral group, the thickness of the interventricular septum was significantly reduced postoperatively, with resultant relief of the left ventricular outflow tract obstruction [89.37 (27.5) vs 10.51 (0.65) mmHg, P < 0.01]. Transaortic myectomy also resulted in a significant reduction in left ventricular outflow tract gradient [90.41 (33.31) vs 11.35 (9.43) mmHg, P < 0.01]. And the incidence of residual systolic anterior motion of the trans-mitral group and the transaortic group was 2.67% and 1.9%, respectively. The thoracoscopic trans-mitral approach provides excellent exposure to the septum and anomalies of the mitral valve and papillary muscle. It relieves obstruction effectively, without increasing the incidence of major complications.

Indications, trends, and perioperative outcomes of minimally invasive and open liver surgery in non-obese and obese patients: An international multicentre propensity score matched retrospective cohort study of 9963 patients

BackgroundDespite the worldwide increase of both obesity and the use of minimally invasive liver surgery (MILS), evidence regarding the safety and eventual benefits of MILS in obese patients is scarce. The aim of this study was therefore to compare the outcomes of non-obese and obese patients (BMI 18.5–29.9 and BMI≥30, respectively) undergoing MILS and OLS, and to assess trends in MILS use among obese patients. MethodsIn this retrospective cohort study, patients operated at 20 hospitals in eight countries (2009–2019) were included and the characteristics and outcomes of non-obese and obese patients were compared. Thereafter, the outcomes of MILS and OLS were compared in both groups after propensity-score matching (PSM). Changes in the adoption of MILS during the study period were investigated. ResultsOverall, 9963 patients were included (MILS: n = 4687; OLS: n = 5276). Compared to non-obese patients (n = 7986), obese patients(n = 1977) were more often comorbid, less often received preoperative chemotherapy or had a history of previous hepatectomy, had longer operation durations and more intraoperative blood loss (IOBL), paralleling significantly higher rates of wound- and respiratory-related complications. After PSM, MILS, compared to OLS, was associated, among both non-obese and obese patients, with less IOBL (200 ml vs 320 ml, 200 ml vs 400 ml, respectively), lower rates of transfusions (6.6% vs 12.8%, 4.7% vs 14.7%), complications (26.1% vs 35%, 24.9% vs 34%), bile leaks(4% vs 7%, 1.8% vs 4.9%), liver failure (0.7% vs 2.3%, 0.2% vs 2.1%), and a shorter length of stay(5 vs 7 and 4 vs 7 days). A cautious implementation of MILS over time in obese patients (42.1%–53%, p < .001) was paralleled by stable severe morbidity (p = .433) and mortality (p = .423) rates, despite an accompanying gradual increase in surgical complexity. ConclusionsMILS is increasingly adopted and associated with perioperative benefits in both non-obese and obese patients.

Tranexamic Acid Administration at Hospital Admission Decreases Transfusion Rates in Geriatric Hip Fracture Patients Undergoing Surgery.

IntroductionThe timing of tranexamic acid (TXA) administration in fragility hip fracture patients is controversial. Prior studies have demonstrated reduction in transfusion requirements using the two-dose arthroplasty model. However, unlike arthroplasty patients whose bleeding starts at the time of surgical incision, hip fractures have an onset of bleeding at the time of the injury. The primary goal of this study was to evaluate the optimal timing of TXA administration and to determine its effect on red blood cell transfusions in fragility hip fracture patients.MethodsAll patients admitted to the fragility hip fracture service from April 1, 2019 to September 30, 2019 were prospectively screened for inclusion in the study. Eligible patients received 4 intravenous doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture >48 hours prior to presentation. A subset of patients received only admission TXA dosing and a separate subset of patients received only incision and post op TXA dosing. Red blood cell transfusions, major adverse vascular events, and minor drug and infusion-related adverse events were recorded for all subgroups of patients.ResultsA total of 508 patients were eligible for analysis. In total, 180 patients received no TXA, 32 patients only received the admission doses of TXA, 112 patients received only the arthroplasty based (incision and post op) doses of TXA, and 183 patients received all 4 doses of TXA. The transfusion rate was significantly lower in patients who received all 4 doses of TXA (8.7%) and in those who only received one dose of TXA at admission (9.4%) compared to patients who received TXA at incision and recovery room (25.7%) or those patients who did not receive TXA prophylaxis (29.4%) (P = 0.001). Additionally, the transfusion rate for intramedullary nailing was higher compared to patients undergoing any other procedure (27% vs 13.8%, P < 0.001).ConclusionsPatients with fragility hip fractures who received IV TXA at hospital admission have significantly lower transfusion rates compared to those who received no tranexamic acid or those who received two dose-TXA (at the operative incision and in the post-operative recovery room). These findings suggest that isolated dosing of TXA at hospital admission may be more effective at reducing post-operative bleeding than the traditional arthroplasty dosing (incision and post-op doses) and is equally as effective as the 4-dose TXA protocol in hip fracture patients undergoing surgery.

ROBOT YARDIMLI CERRAHİ GİRİŞİMLERDE İKİNCİ GÜVENLİ CERRAHİ KONTROL LİSTESİ KULLANIMININ ÖNEMİ (THE SECOND “TIME-OUT”)

Teknolojideki önemli gelişmeler cerrahi süreçleri de etkileyerek ameliyatlarda yeni tekniklerin kullanılmasına olanak sağladı. Ameliyatlarda geleneksel yöntemlerin yanı sıra robotlar da kullanılmaya başlandı. Robotların kullanılmasıyla gerçekleştirilen cerrahi girişimler “Robotik Cerrahi” olarak adlandırılmakta olup, insanlık için yeni ufuklar açan ve sürekli gelişen güncel bir teknolojidir. Robotik cerrahi, daha az kan kaybı, daha düşük transfüzyon hızı ve kısa iyileşme süresi gibi avantajları nedeniyle hastalar, cerrahlar ve hemşireler için birçok avantaja sahiptir. Hemşirelerin, teknolojik gelişmeleri takip ederek uyum sağlamaları ve profesyonel hemşirelik rollerini artırmaları beklenmektedir. Robotik cerrahide diğer önemli konu da hasta güvenliği olup, hastanın pozisyonu özel bir endişe kaynağıdır. Robotik cerrahi sonrası gelişebilecek komplikasyonlar, hasta pozisyonunun uygun olmaması ve hasta güvenliğinin tam sağlanmamasından kaynaklanabilir. Dünya Sağlık Örgütü’nün 2008 yılında yayınladığı güvenli cerrahi kontrol listesinde yer alan “time-out”un uygulanması ile perioperatif süreçte morbidite ve mortalitede azalma olduğu belirlenmiştir. Robotik cerrahi ameliyatlarında, ameliyat başladıktan 3-4 saat sonra “time-out” un tekrar uygulanmasıyla gelişebilecek komplikasyonlar önlenebilmektedir. Bu makalede robotik cerrahide ikinci güvenli cerrahi kontrol listesinin ülkemiz koşullarına uyarlanması amaçlandı.

Comparison of mini percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for renal stones >2cm: a systematic review and meta-analysis.

ABSTRACTBackground The purpose is to compare the efficacy and safety of mini percutaneous nephrolithotomy (mini-PCNL) versus standard percutaneous nephrolithotomy (standard-PCNL) in patients with renal stones >2cm.Materials and Methods A systematic literature search was conducted in PubMed, Web of Science, Scopus, and the Cochrane Library databases to identify relevant studies before March 8, 2021. Stone-free rate (SFR), operation time, fever rate, hemoglobin drop, blood transfusion rate, and hospitalization time were used as outcomes to compare mini-PCNL and standard-PCNL. The meta-analysis was performed using the Review Manager version 5.4.Results Seven randomized controlled trials were included in our meta-analysis, involving 1407 mini-PCNL cases and 1436 standard-PCNL cases. Our results reveal that, for renal stones >2cm, mini-PCNL has a similar SFR (risk ratio (RR)=1.01, 95% confidence interval (CI): 0.98 to 1.04, p=0.57) and fever rate (RR=1.22, 95% CI: 0.97-1.51, p=0.08). Standard-PCNL was associated with a significantly shorter operating time (weighted mean difference (WMD)=8.23, 95% CI: 3.44 to 13.01, p <0.01) and a longer hospitalization time (WMD=-20.05, 95% CI: -29.28 to -10.81, p <0.01) than mini-PCNL. Subgroup analysis showed hemoglobin drop and blood transfusion for 30F standard-PCNL were more common than mini-PCNL (WMD=-0.95, 95% CI: -1.40 to -0.50, p <0.01; RR=0.20, 95% CI: 0.07 to 0.58, p <0.01).Conclusion In the treatment of >2cm renal stones, mini-PCNL should be considered an effective and reliable alternative to standard-PCNL (30F). It achieves a comparable SFR to standard-PCNL, but with less blood loss, lower transfusion rate, and shorter hospitalization. However, the mini-PCNL does not show a significant advantage over the 24F standard-PCNL. On the contrary, this procedure takes a longer operation time.Trial registration This meta-analysis was reported consistent with the PRISMA statement and was registered on PROSPERO, with registration number 2021CRD42021234893.

Die minimal-invasive Chirurgie beim Blasenkarzinom – Vorteile und neue Entwicklungen

BackgroundRadical cystectomy (RC) is a core component of the treatment of localized muscle-invasive bladder cancer. This is a complex procedure that is associated with significant perioperative morbidity and mortality. Although open RC remains the gold standard, minimally invasive techniques (conventional laparoscopic and robot-assisted) have become firmly established. This article provides an overview of the most important aspects of RC and gives an up to date overview of the evidence for minimally invasive RC.Material and methodsThis article summarizes the current clinically relevant study results on minimally invasive RC together with relevant current guideline recommendations.ResultsNumerous case series have demonstrated the feasibility of minimally invasive RC but do not allow valid comparisons to open surgery. Randomized controlled trials showed significantly lower blood loss, lower transfusion rates and faster postoperative recovery to be the main advantages of minimally invasive RC. No differences were found in terms of oncological outcome and postoperative morbidity and mortality; however, patient numbers were small and the studies were not powered to detect the respective differences.ConclusionMinimally invasive RC is a complex procedure, which offers the typical advantages of laparoscopic techniques; however, more studies comparing minimally invasive RC with intracorporeal urinary diversion by open surgery are needed. Due to a steep learning curve minimally invasive RC will probably remain limited to high-volume centers.

Dynamic hip screw versus intramedullary nailing for the treatment of A1 intertrochanteric fractures: A retrospective, comparative study and cost analysis.

Objectives This study aims to compare sliding hip screw and intramedullary nail perioperative results and costs in two-part femoral fractures.Patients and methods Between January 2015 and December 2019, a total of 85 patients (70 males, 15 females; mean age: 85.6±9.5 years; range, 33 to 99 years) who were treated for intertrochanteric two-part femoral fractures were retrospectively analyzed. The patients were stratified and divided into two groups according to type of implant used for surgical fixation: one group treated with intramedullary proximal femoral nail (EBA) and the other with sliding hip screw (DHS). Comorbidity, hemoglobin level (Hb), hematocrit (hct) level, number of transfusions, and days of hospitalization details were evaluated. Postoperative X-rays were analyzed to assess the quality of reduction and to identify non-union, malunion, mechanical failures, and heterotopic ossifications. The modified Harris Hip Score, fracture mobility score, and Parker Mobility Score were calculated. Cost analysis considered the orthopedic device, operating room, transfusion, and hospital costs for the primary hospital stay.Results Of the patients, 44 were treated with DHS and 41 were treated with EBA nail by a single surgeon. No significant differences were found in the baseline demographic data. There was a significant increased operative time (p<0.001) and decreased fluoroscopy X-ray exposure time (p=0.031) in the subgroup of patients who underwent DHS fixation. The patients who underwent EBA nail fixation had a significantly higher transfusion rate during hospitalization (p=0.001) and a significantly lower Hb level and hct level on postoperative Day 1 and Day 3 (p<0.05). There were no significant differences in the clinical and functional scores, radiographic outcomes and mortality (p>0.05). The patients who underwent intramedullary nail fixation had higher costs.Conclusion Sliding hip screws showed decreased postoperative anemization, lower transfusion rates, and similar clinical outcomes compared to the intramedullary nail for two-part femoral fractures. Sliding hip screws should be preferred for A1 intertrochanteric fractures.