Mean Volume Of Blood Loss Research Articles

A Two-Step Control of Secondary Splenic Pedicles Using Ligasure during Laparoscopic Splenectomy

Objective: We modified the LigaSure vessel sealing into a two-step technique without using Endo-GIA stapler for the secondary splenic pedicle control in laparoscopic splenectomy (LS). This study evaluated the efficacy and safety outcomes of this technique.Methods: Patients (n = 105) scheduled for elective LS were consecutively and prospectively enrolled, including 24 males and 81 females, with a mean age of 43.6 (range 11-75) years. Following the mobilization of the spleen, the splenic inflow was interrupted by applying a Hem-o-lock clip. LigaSure was used to seal and transect the secondary splenic pedicles adjacent to the pancreatic tail and subsequently in proximity to the spleen.Results: Of 105 patients, 103 patients (98.1%) underwent successful LS, whereas two patients (1.9%) required the conversion to laparotomy. The mean operative time was 100 min, whilst the mean volume of blood loss was 500 mL. No clinically significant morbidities or mortality occurred following LS. An average of 8,000 RMB (range: 6900 to 9000; 1 USD = 6.5 RMB) was saved by using this two-step technique.Conclusion: Secondary splenic pedicles can be successfully controlled in LS by using a two-step technique with the LigaSure vessel sealing system in an economically favorable way.

Computer-assisted C1-C2 Transarticular Screw Fixation "Magerl Technique" for Atlantoaxial Instability

Study DesignA retrospective study.PurposeTo evaluate the surgical results of computer-assisted C1-C2 transarticular screw fixation for atlantoaxial instability and the usefulness of the navigation system.Overview of LiteratureWe used a computed tomography (CT)-based computer navigation system in planning and screw insertion in Magerl's procedure, which provides the most rigid atlantoaxial fusion, to avoid risk of vertebral artery (VA) tear by avoiding high-riding VA during screw insertion.MethodsTwenty patients who underwent atlantoaxial fusion under the CT-based navigation system were studied. The mean observation period was 33.5 months. The evaluated items included the existence of VA stenosis by preoperative magnetic resonance angiography, surgical time, blood loss volume, Japanese Orthopaedic Association (JOA) score and Ranawat's pain criteria before surgery and at final follow-up, postoperative screw position evaluated by CT, and bony fusion.ResultsThe mean operation time was 205 minutes, with the mean blood loss volume of 242 ml. The mean JOA score was 11.6 points before surgery and 13.7 at final follow-up. Occipital and/or cervical pain presented before operation was remitted or resolved in all patients. Evaluation of screw insertion by CT revealed correct penetration to atlantoaxial joints, with a perforation rate of 2.6%. There was no complication, including VA tear, and all patients who were followed-up during one year or more after surgery achieved bony fusion. Some subjects who appeared inappropriate for surgery from CT images were assessed as eligible for surgery based on the evaluation results obtained using the navigation system.ConclusionsIt was demonstrated that the CT-based navigation system is an effective support device for Magerl's procedure.

Thromboprophylaxis with dabigatran etexilate in patients over seventy-five years of age with moderate renal impairment undergoing or knee replacement

Prospective, double-blind studies in orthopaedic patients have been conducted using the direct thrombin inhibitor dabigatran etexilate (hereafter referred to as dabigatran), with two doses investigated and approved for adults (220 mg and 150 mg once daily) to prevent venous thromboembolism (VTE). The European Medicines Agency decided that in major joint orthopaedic surgery, the lower dose should be used in elderly patients (aged over 75 years) and those with reduced renal function (creatinine clearance between 30 and 50 ml/min). Our objective was to understand the efficacy and bleeding data for the lower dose in this subpopulation. We extracted and analysed data from the elderly or from moderately renally impaired patients (n 632 of = 5,539) from the orthopaedic clinical development programme of dabigatran. Dabigatran 150 mg once daily was as effective as the standard European enoxaparin regimen, with numerically fewer major bleeding events. Rates of major VTE were 4.3% vs 6.4% of patients, respectively. Major bleeding events occurred in four (1.3%) vs 11 (3.3%), which shows a trend towards lower bleeding with dabigatran 150 mg [odds ratio (OR) 0.40; 95% confidence interval (CI) 0.13-1.25; p = 0.110]. Mean volume of blood loss was 395 vs 417 ml, and transfused units were 2.4 vs 2.5, respectively. Other safety parameters, including the incidence of wound infections and complications, were similar for 150 mg once daily dabigatran and enoxaparin. For patients at higher risk of bleeding, dabigatran 150 mg once daily is as effective as enoxaparin following major orthopaedic surgery and is associated with a favourable bleeding rate.

Occipitocervical fixation in the management of craniocervical instabilities

IntroductionThe occipitocervical junction presents a unique, complex, biomechanical interface between the cranium and the upper cervical spine. Occipitocervical fixation has undergone significant evolution due to advances in operative techniques and instrumentation techniques. ObjectiveThis study was done to evaluate clinical picture, radiographic findings and results of occipitocervical fusion in 10 patients with craniocervical instabilities. Also to compare these results with other results reported in the literature. MethodsThis retrospective study reviewed 10 patients who underwent occipitocervical fixation for craniocervical instabilities between April 2007 and October 2010 in Alexandria hospitals. There were 7 males and 3 females and their ages ranged from 16 to 63 years with mean age of 42.1 years. As regards the clinical presentation, all patients had presented with neck pain before surgery, 8 patients (80%) with myelopathy, and 8 patients (80%) had presented with a neurological deficit either motor or sensory or both. The etiologies of occipitocervical instability in this study were trauma in three patients, rheumatoid arthritis in three patients, tumor in two patients and Down syndrome in two patients. All patients had preoperative craniocervical plain X-ray, CT and MRI examination. All patients underwent occipitocervical fixation surgery with various fixation systems and autologous bone grafts for fusion. Fusion was assessed by plain cervical X-ray films and CT scan, and the neurological outcome by Frankel grade. The mean follow-up period was 14.7 months (range, 4–24 months) including both clinical and radiological examinations. ResultsThere were no operative mortalities or vascular injuries in this series. Two patients showed transient neurological deterioration postoperatively that had resolved within three months. Two cases had superficial wound infection and one case had cerebrospinal fluid leak. The mean operation time was 207 min (range 130–320 min) and the mean volume of blood loss was 354 mL (range 120–750 mL). Neck pain improved in all patients and no new instability developed at adjacent levels. Regarding the Frankel grade, five patients had shown improvement (Three patients improved from Frankel grade C to grade D, one patient from grade A to grade B and one patient from grade D to grade E), while five patients remained stationary at the same grade. At the last follow-up examination period, a solid fusion was achieved in nine patients out of ten (90%). ConclusionOcciptocervical fixation is indicated in the management of craniocervical instabilities resulting from trauma, rheumatoid arthritis, tumors and congenital anomalies of the craniocervical junction. Accurate imaging studies and proper patient selection are the keys to a successful outcome. Occipitocervical fusion procedures can be performed with low morbidity. A comprehensive knowledge of the anatomy of the occipital-cervical junction is imperative. A wide variety of stabilization techniques and instrumentation systems are currently available, each of which has its own advantages and disadvantages.

Retroperitoneal Laparoscopic Partial Nephrectomy for Renal-Cell Carcinoma in a Solitary Kidney: Report of 56 Cases

The aim of this study was to evaluate the possibility and clinical efficacy of retroperitoneal laparoscopic partial nephrectomy for T(1)- and T(2)-stage renal-cell carcinoma (RCC) of a solitary kidney. A total of 56 patients with RCC in a solitary kidney were selected in this study, including 41 men and 15 women with a mean age of 49 years. B-type ultrasonography and CT revealed T(1)N(0)M(0) tumors in 51 cases and T(2)N(0)M(0) tumors in the remaining 5 cases; 41 cases were RCC in left kidney, and 15 were RCC in right kidney. Of them, 24 cases had RCC located in the upper pole, 24 in the inferior pole, and 8 in the central region of the kidney. The mean tumor diameter was 3.0 +/- 0.8 cm (1.5-5.5 cm). Postoperative pathology report showed 46 cases of T(1)-stage tumor (T(1a): 38; T(1b): 8) and 10 cases of T(2) stage. Retroperitoneal laparoscopic nephron-sparing surgery was performed. Surgical resection was performed along a resection line 0.5 cm from the tumors. Renal function was determined using emission CT before and after operation. Preoperative three-dimensional CT image reconstruction was performed using multislice spiral CT. All procedures were successfully performed without open conversion and serious complications. The mean warm ischemia time was 24 +/- 4.2 minutes (19-50 minutes). The mean operation time was 95 +/- 14.5 minutes. The mean blood loss volume was 105 +/- 20.4 mL. No postoperative urine leakage occurred. Both serum creatinine and nitrogen levels were normal after operation in all cases. The mean hospital stay was 9 +/- 2 days. There was no requirement for hemodialysis. No recurrence, metastasis, and implantation were observed during the 20 +/- 4 month follow-up periods, with a survival rate of 100%. Laparoscopic partial nephrectomy can be performed safely and effectively in selected patients with tumors in a solitary kidney owing to its minimal invasion, clear dissection, less hemorrhage, and rapid recovery.

Thoracoscopy assisted Nuss procedure for pectus excavatum correction

To evaluate the short-term effect and experience of Nuss procedure on 120 cases of patients with pectus excavatum. Thoracoscopy assisted Nuss procedure with different ways of anesthesia were applied to 120 cases of patients with pectus excavatum, including 7 cases of recurrence after traditional surgical procedure (6 cases) and Nuss method (another one). The patients ranged in age from 2.5 to 43 (mean 14.1) years and in Haller index from 2.91 to 29. Of the 120, 73 had symmetric and 47 had asymmetric pectus excavatum. The Nuss procedure is performed with general anesthesia and a convex steel bar is inserted under the sternum with thoracoscopy through small bilateral thoracic incisions. The steel bar is inserted with the convexity facing posteriorly, and when it is in position, the bar is turned over, thereby correcting the deformity. The operation was successfully accomplished without severe complications in all the 120 cases. The mean operative time was 58 minutes and the mean volume of blood loss was 30 ml. 103 patients had one bar inserted while the other 17 cases with more extremely diffuse depression required 2 or even 3 bars to get a satisfactory correction. Such methods as modifications to the fixing points and the shape of the bar, partial osteotomy, were developed to deal with asymmetric ones. The Nuss procedure is a minimally invasive technique for correction of pectus excavatum. It can lead to a satisfactory outcome and surgical time is less.

Retroperitoneal laparoscopic resection for pheochromocytoma (experience of 107 cases)

To evaluate the safety and efficacy of retroperitoneal laparoscopic resection for pheochromocytoma. The clinical data of 107 cases of pheochromocytoma in PUMCH from 2003 to 2008 were analyzed retrospectively. There were 58 males and 49 females with an age range from 8 to 77 years (mean 44 years) in this cohort. One hundred and two cases were intra-adrenal and 5 extra-adrenal. Of the 102 intra-adrenal tumors, 43 tumors were located in left adrenal, 51 in right adrenal and 8 in both sides. All of the 5 extra-adrenal tumors were at para-abdominal aorta. Retroperitoneal laparoscopic resection was performed for the 107 cases. This period was separated to 3 stages based on the degrees of the practical ability for retroperitoneal laparoscopic resection, such as tentative and exploratory stage, accumulative stage, and mature stage. At tentative and exploratory stage from June 2003 to December 2003, 10 cases underwent retroperitoneal laparoscopic surgery, of which 3 cases were converted to open surgery. The mean diameter was 4.2 cm (range in diameter from 2.5 cm to 6.0 cm). The mean operation time was 105 min (range from 60 min to 230 min). The mean volume of blood loss during operation was 620 ml (range from 150 ml to 1800 ml). At accumulative stage from January 2004 to December 2006, 66 cases underwent retroperitoneal laparoscopic surgery with none converted to open surgery. The mean diameter was 5.7 cm (range in diameter from 2.1 cm to 8.7 cm), and the diameter was above 6.0 cm in 19 cases. The mean operation time was 95 min (range from 40 min to 210 min). The mean volume of blood loss during operation was 350 ml (range from 50 ml to 1800 ml). At mature stage from January 2007 to June 2008, 31 cases, including 5 extra-adrenal pheochromocytomas, underwent retroperitoneal laparoscopic surgery. The mean diameter was 6.5 (range in diameter from 1.5 cm to 12.3 cm). The mean operation time was 75 min (range from 40 min to 160 min). The mean volume of blood loss during operation was 180 ml (range from 50 ml to 800 ml). No peri-operative death occurred. Follow up period was ranging from 1 to 62 months (the mean was 34 months), and 7 failed to be followed up, 3 cases recurred. And there was no distant metastases and death case. Retroperitoneal laparoscopic surgery for pheochromocytoma is feasible and safe. This procedure will be more and more performed as the advancement of the skill and accumulation of experience. The dimension, recurrence and location of tumor are not the absolute contraindication of retroperitoneal laparoscopic surgery for pheochromocytoma.

Comparison of Blood Loss according to Different Anesthetic Technique for Total Hip Replacement

The mean blood loss is about 500−1,700 ml by general anesthesia technique in total hip replacement (THR) and the amount of blood loss is dependent on the degree of induced hypotension. We performed this study to evaluate the differences on the amount of blood loss and the number of transfused patients according to different anesthetic technique under the similar hypotension level. Methods: Forty-seven patients of ASA physical status class 1, 2 and 3, scheduled for THR, were randomly assigned into epidural anesthesia group (E group), combined general epidural anesthesia group (GE group) and general anesthesia group (G group). G group was maintained with sevoflurane anesthesia and the monitoring of central and arterial blood pressure was performed. The remifentanil (0.1μg/kg/min) was infused continuously for the target mean arterial pressure of 60 ± 5 mmHg. GE group received general anesthesia with the same technique of G group and epidural anestheia was combined after general anesthesia. The remifentanil (0.1μg/kg/min) was infused continuously for the target mean arterial blood pressure of 60 ± 5 mmHg. E group received epidural anesthesia with 0.75% ropivacaine and additional bolus dose of local anesthetics was injected if the mean arterial blood pressure did not reach 60 ± 5 mmHg. Results: The mean volume of blood loss and the number of transfused patients was significantly less in E or GE group at 24 hour after surgery (P ＜ 0.05), however we could not find any significant differences during intraoperative period. Conclusions: Epidural or combined general epidural anesthesia technique is a good method to reduce bleeding and the number of transfused patients.

Stoma formation for fecal diversion: a plea for the laparoscopic approach

The aim of this study was to assess the results of laparoscopic stoma creation for fecal diversion, specifically focussing on feasibility, safety, and efficacy, as well as indications and techniques. Within a 10-year-period, all patients requiring laparoscopic stoma creation were evaluated prospectively. Patients' profiles and indications, procedures and results of operation, conversion, morbidity, mortality and short-term complications (stoma-related, laparoscopy-associated) were analyzed. A total of 80 patients (39 males, 41 females) with a mean age of 55.5 years (range, 17-91) underwent laparoscopic stoma creation. Most common indications were unresectable advanced colorectal cancer (n=20), pelvic malignant cancer (e. g. ovarian, cervix and prostate cancer, n=16), and perianal Crohn's disease with complex fistulas (n=16). Only in one female patient with pelvic malignant disease was the procedure converted to laparotomy due to obesity (conversion rate, 1.3%). 79 patients underwent laparoscopic stoma creation (completion rate, 98.7%) including loop ileostomy (n=30), loop sigmoid colostomy (n=40) and end sigmoid colostomy (n=9). Postoperative complications were documented in 9 patients (overall morbidity rate, 11.4%), including 4 minor complications treated conservatively (2 cases of prolonged atonia and 1 case each of pneumonia and urinary tract infection) and 5 major complications requiring reoperation (reoperation rate, 6.3%): one parastomal abscess (drainage), one stoma retraction following rod dislocation (laparoscopic stoma recreation), small bowel obstruction in two patients (small bowel resection), one port-site hernia (fascial closure), and hemorrhage (managed by re-laparoscopy). Mean operation time was 74 min (range, 30-245 min). Mean blood loss volume was 80 ml (range, 30-400 ml). Patients were discharged from hospital after a mean of 10.3 days (range, 3-47). Within a 1-year follow-up, no further stoma complications were documented. The advantages of laparoscopic stoma creation are low morbidity and reoperation rates, and no procedure-related mortality; our results suggest that laparoscopic stoma creation for fecal diversion is safe, feasible and effective. Therefore, at our institution, laparoscopic stoma creation is the method of choice for fecal diversion.

Laparoscopic adrenalectomy in patients with large adrenal tumors

The maximum size of adrenal tumors that should be removed by laparoscopic adrenalectomy is controversial. We conducted a retrospective comparison of the results of laparoscopic adrenalectomy between patients with adrenal tumors > or =6 cm ('large tumors') and patients with adrenal tumors <6 cm ('small tumors'). The participants in the study were 16 patients with large tumors and 111 patients with small tumors. The patients comprised 59 men and 68 women (mean age, 49.0 years; age range, 23-79) with varying diagnoses. Of the 16 patients with large tumors, five had Cushing's syndrome, four had pheochromocytomas, six had a non-functional tumor and one had malignant lymphoma. Adrenal tumors were confirmed by hormonal assays, biochemical tests and computed tomography. Of the 16 large tumors, five tumors were on the right and 11 were on the left. We found no significant differences in general demographic parameters between patients with large and small tumors. The mean duration of surgery was not significantly different between two groups. (large tumors, 210 min; small tumors,175 min). The mean volume of blood loss was 212 mL for large tumors and 30 mL for small tumors (P < 0.001, significant difference). There was no significant difference in time until walking, duration of hospitalization or number of using analgesics used. The time to first oral intake of group 1 (<6 cm) was significantly shorter than group 2 (> or =6 cm). Tumor size (> or =7.5 cm) was an independent predictor of a longer operation and greater blood loss in large tumors. Laparoscopic adrenalectomy for large tumors was safe and minimally invasive.

Radiographic and Functional Outcome After Surgical Management of Severe Scoliosis in Skeletally Immature Patients with Muscular Dystrophy

Most patients with muscular dystrophy (MD) develop progressive scoliosis after losing ambulatory status, but some cases develop severe scoliosis at a skeletally immature age before losing ambulatory status. Only a few studies have been conducted in skeletally immature patients with severe scoliosis. The purpose of this study was to assess the functional and cosmetic outcome in skeletally immature patients with severe scoliosis. Preoperative, immediate postoperative, and final follow-up radiographs were analyzed in 10 consecutive skeletally immature patients with respect to the Cobb angle degree and the pelvic obliquity angle correction, how long the correction was maintained, and the development of the crankshaft phenomenon. In the functional assessment, the ability to sit balanced, according to the Mulcahy method, and the ability to use hands, according to the Rhyu method, were evaluated. Furthermore, the degree of subjective satisfaction was evaluated in these patients. The average age of the patients was 10.4 years, and the average follow-up period was 33 months with minimum 2 years' follow-up. All 10 patients survived and were available at the follow-up. The mean Cobb and pelvic obliquity angles were 80 degrees and 17 degrees at the time of the surgery, 31 degrees and 3.7 degrees immediately after the surgery, and 35 degrees and 4.7 degrees at the time of the final follow-up, respectively. The initial mean Cobb angle correction averaged 61%, with 78% of pelvic obliquity corrected. These corrections were maintained over time in most cases. At the time of the surgery, the mean volume of blood loss was 1111 mL, with an average operation time of 411 minutes. There were no major complications. At the time of the last follow-up, no patient showed development of the crankshaft phenomenon. The average score for the ability to sit balanced improved from 4.4 to 6.6 according to the Mulcahy evaluation method. The scores for hand use were 2.2-2.7. However, the forced vital capacity of the lungs decreased from a preoperative 48% to 46.1%. These results indicate that even in very young MD patients with severe scoliosis, acceptable curve correction can be achieved and maintained with surgery. The improved pelvic obliquity and scoliosis angle stabilized the spine, freeing the upper extremities and allowing productive activities characteristic of childhood.

Intérêt de l’utilisation d’un sac de recueil dans le diagnostic des hémorragies de la délivrance

Depending on the country and the publications, post-partum hemorrhage (PPH) is either the first or second cause of maternal death in the world, including in developed countries. It remains a significant source of morbidity, severe anemia, blood transfusion, transfusion complications, acquired coagulation disorders and hemostasis hysterectomy. Visual assessment underestimates the amount of blood loss in around 45% of cases. Emergency treatment is therefore sometimes undertaken with some delay, giving time for Disseminated Intravascular Coagulation (DIC) to occur, which worsens the prognosis. A collecting plastic bag put under the pelvis of the mother just after delivery is a quantitative and objective method of measuring blood loss. The objective was to assess sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), studying correlation between bag's volume and hemoglobin and hematocrit variation. Included outpatients were women with unique pregnancy at term. Breech presentations were excluded. We measured serum hemoglobin and hematocrit just after admission for labor. A collecting bag, placed under the pelvis of each woman just after birth, was weighted after delivery. Serum hemoglobin and hematocrit were again assessed at three days. Post-partum hemorrhage was defined by a fall of hematocrit more than 10 points (delta Ht), or by a fall of hemoglobin more than 3g/dL (delta Hb). From January 2003 to May 2003, 272 patients were included. 8.9% of the results were unuseful (n=24). The mean volume of blood loss was 190 ml (5th p=29 ml, 10th p=48 ml, 90th p=610 ml, 95th p=824 ml). The mean delta Ht was 2.7 +/- 4 pts (16.5 / -4.8). The mean delta Hb was 1.2 +/- 1.4 g/dL (5.9 / -1.5). For a delta Ht=10 the calculated bag volume was 564 ml. With this cut off we noted 5.5% PPH (n=15) prevalence=0.06. Sensitivity=34.21%. Specificity=99%. PPV=86%. NPV=90.38%. For a delta Hb=3 the calculated bag volume was 486 ml. With this cut off we noted 10.7% PPH (n=24) prevalence of PPH=0.1. Sensitivity=38.77%. Specificity=95.96%, PPV=67. 85%. NPV=87.7%. The collecting pelvis bag is a rapid and precise procedure to diagnose PPH in the delivery room. It also enables a visual and quantitative non-subjective estimation of blood loss. Because of its simplicity and very low cost, the collecting pelvis bag should be used widely as a routine preventive measure.

Effect of preoperative discontinuation of antipsychotics in schizophrenic patients on outcome during and after anaesthesia

Effect of preoperative discontinuation of antipsychotics in schizophrenic patients on outcome during and after anaesthesia

Summary Reconstruction of the oral floor by suture of the platysma and digastric muscle:

Fifteen patients with oral and oropharyngeal cancer who underwent en-bloc resection with subsequent reconstruction of the oral floor by suture of the platysma and digastric muscle without free flap were reviewed. We analyzed the treatment method, clinical course, complications and quality of speech by the 10-point scoring system of Hirose. En-bloc continuous resection of the primary lesion and neck dissection were performed by the pull-through procedure or commando operation. We separated the excised cervical wound and oral cavity by suturing between the platysma and the digastric muscle. The primary lesion was located on the oral tongue in 8 patients, on the lower gum in 4 patients, on the oral floor in 2 patients and on the tonsillar f ossa in 1 patient. The patients consisted of 13 males and 2 females, with ages ranging from 28 to 81 years and a mean age of 63 years. Tracheostomy was performed in 6 patients. Five patients with lower gum or oral floor cancer underwent mandibulectomy. Two patients had received radiation for previous head and neck cancers. The mean operative time was 290 minutes. The mean volume of blood loss was 227ml. Complications occurred in 6 patients. Local small abscesses occurred in 3 patients, mild laryngeal edema occurred in 1 patient, mild laryngeal edema and a fistula occurred in 1 patient, and aspiration pneumonia occurred in 1 patient. The mean period until oral intake was 15 days. Speech intelligibility was excellent in 14 patients and moderate in 1 patient. This method is useful and effective. In advanced oral or oropharyngeal cancer requiring reconstruction by free flap, we partially use this method. But for better functional improvement, exclusive use of a free flap is much better. The indication of this method should be carefully decided.

Impact of blood sampling in very preterm infants

In a prospective investigation, 99 very preterm infants (gestational age (GA) 24-32 weeks, birthweight 560-2255 g) were studied during the first 4 weeks of life. The infants were divided into two groups: infants born extremely early (GA<28 weeks, n=20) and infants of GA 28-32 weeks; the groups were then subdivided into critically ill or not. Diagnostic blood sampling and blood transfusion events were recorded. In total, 1905 blood samples (5253 analysis) were performed, corresponding to 0.7 samples (1.9 analysis) per day per infant. The highest frequencies were found during the first week, in infants with extremely low GA and in critically ill infants. The mean blood loss and transfusion volume values were 13.6 ml/kg and 6.3 ml/kg, respectively. In total, 19 infants (19%) received 34 transfusions corresponding to 0.3 transfusions per infant. Thirteen out of 20 infants of extremely low GA received 28 blood transfusions, corresponding to 27.0 ml/kg of blood on average during the study period. Four developed late anaemia; thus, in total, 14 (70%) of the infants born extremely early received 35 transfusions during the first 3 months of life, corresponding to a total mean of 34.8 ml/kg. For the extremely preterm infants a significant correlation between sampled and transfused blood volume was found (mean 37.1 and 33.3 ml/kg, respectively, r=+0.71, p=0.0003). The most frequently requested analyses were glucose, sodium and potassium. Few blood gas analyses were requested (1.9/infant). No blood losses attributable to excessive generous sampling were detected. The results show an acceptable low frequency of sampling and transfusion events for infants of GA 28-32 weeks. The study emphasizes the necessity of thorough reflection and monitoring of blood losses when ordering blood sampling in extremely preterm, critically ill infants.

Video-assisted thoracoscopic esophagectomy for esophageal cancer.

The Ivor-Lewis procedure is a radical, invasive, and effective procedure for the resection of most esophageal cancers. To minimize invasiveness, we performed thoracoscopic and video-assisted esophagectomy and mediastinal dissection for esophageal cancer. From November 1995 to June 1997, 23 patients with intrathoracic esophageal cancer, excluding T4 cancers, underwent thoracoscopic and video-assisted esophagectomy. Bilateral cervical dissections were performed as well as preparation of the gastric tube and transhiatal dissection of the lower esophagus. The cervical esophagus was cut using a stapler knife, and esophageal reconstruction was performed through the retrosternal route or anterior chest wall. Next, thoracoscopic mediastinal dissection and esophagectomy were performed. The mean volume of blood loss was 163 +/- 122 ml; mean thoracoscopic surgery duration, 111 +/- 24 min; mean postoperative day for patients to start eating, 8 +/- 3 days; and mean hospital stay, 26 +/- 8 days. No patient developed systemic inflammatory response syndrome postoperatively. Tracheal injury occurred and was repaired during the thoracoscopic approach in one patient. No patients died within 30 days after surgery. Postoperative complications included transient recurrent nerve palsy in five patients, pulmonary secretion retention requiring tracheotomy in two, and chylothorax in one. Five patients died of cancer recurrence within 1 year of surgery. Our surgical experience with thoracoscopic and video-assisted esophagectomy indicate that it is a feasible and useful procedure.

Intraoperative blood salvage in abdominal uterine myomectomy

Objective: To study the safety and efficacy of intraoperative blood salvage in abdominal uterine myomectomy. Method: Thirty-seven patients with a clinical diagnosis of uterine myoma who underwent abdominal uterine myomectomy were treated with an intraoperative blood salvage apparatus, Cell Saver, and compared with the patients without autotransfusion. Result: Thirty-five patients received autologous blood transfusion alone and only two patients required additional homologous transfusion. The hemoglobin of processed and reinfused blood was proportional to the volume of intraoperative blood loss. There were no adverse reactions related to autologous transfusion. In the patients with more than 500 ml of blood loss, the mean blood loss volume in the Cell Saver group was higher than that in the control group, and the postoperative hemoglobin level was also higher. Conclusion: Intraoperative blood salvage was safe and certainly promising for patients with heavy blood loss during abdominal uterine myomectomy.

Laparoscopic-Assisted Surgery of the Spleen: Clinical Experience in Expanding Indications

Between January 1993 and November 1995 laparoscopic surgery was used in 21 patients with a variety of splenic diseases, namely idiopathic thrombocytopenic purpura, congenital spherocytosis, lymphoma, leukemic infiltrative disease, splenic infarction, trauma, or splenic cyst. Total splenectomy was carried out laparoscopically in 16 patients. Conversion to open splenectomy was necessary in two other patients because of intractable bleeding. Two patients with a splenic cyst underwent laparoscopic unroofing of the cyst. Conservative hemostasis of a spleen injury grade II was carried out in a child after blunt trauma. The total mean duration of the laparoscopic procedures was 158 min and the mean blood loss volume was 350 ml, both conversions being excluded. Postsurgical recovery was excellent and the average hospital stay was 5 days, including the patients with conversion. There were no significant postoperative complications. Our observations indicate that an increasing number of surgical diseases of the spleen can be managed adequately by a less invasive laparoscopic approach. However, the criteria for using this procedure are in an expanding phase and are still mainly dependent on the surgeon's technical experience.

Guidelines for donor selection and an overview of the donor operation in living related liver transplantation

Abstract Guidelines for donor selection and an overview of the donor operation are reported on the basis of our experience with 120 cases of living related liver transplantation (LRLT) in pediatric patients. Once the parents had clearly expressed their desire to serve as donors, tests were performed to functionally and anatomically screen the donor livers to determine whether or not the parents' general physical condition allowed them to serve as donors. We then evaluated which of the two parental candidates was more suitable as a donor. The wishes of the family as to which parent should serve as donor was considered secondary and taken into account only in a few cases in which certain functional and/or anatomical abnormalities were uncovered that made the prime candidate less suitable. For the 120 LRLTs, 135 candidates were evaluated as potential donors, 15 (11.1 %) of whom were rejected for various reasons. The mean volume of blood loss during the donor operation decreased significantly from 489 g in the first 60 LRLTs to 390 g in the latter 60 LRLTs; this was accompanied by a significant decrease in the mean volume of autologous blood transfused from 449 g to 390 g. Mean cold ischemia time of the graft increased significantly from 71.4 to 128.0 min, while mean operation time conversely decreased from 6.7 to 6.2 h. Bile leakage from the cut surface of the remnant liver, which was the only postoperative surgical complication encountered, was noted in five cases. We conclude that donor candidates should be strictly selected according to basic guidelines, taking into account both the results of preopera-tive screening and the wishes of the family. With this accumuled experience, we have been able to simplify our LRLT operative procedure, resulting in decreases in blood loss volume, blood transfused, and operation time.

頭頸部外科手術におけるレーザーの応用

Application of the laser power in the field of surgery has recently begun. In this paper we discuss benefits of Nd-YAG laser using a contact laser probe in the head and neck surgery. Twenty-seven cases of radical neck dissection and sixteen cases of reconstructive surgery using a pedicle myocutaneous island flap were carried out using contact Nd-YAG laser. Contact Nd-YAG laser surgery greatly reduced the volume of blood loss. The mean volume of blood loss was 93ml during radical neck dissection, and 73ml during the preparation of a pedicle myocutaneous island flap. This loss did not require blood transfusion. The volume of blood and exudate from negative pressure drainage after surgery was significantly smaller in laser surgery than in conventional surgery. There was no major complication in our laser operations. Laser probe can be used safely in cutting the skin and mucosal wall and in dissecting subcutaneous tissues since the identification of blood vessels, nerve fibers, and other parts is very easy because the bloodless operation.