Mean Intraoperative Estimated Blood Loss Research Articles

Evaluation of Perioperative Factors Contributing to Organ Space Surgical Site Infection After Minimally Invasive Hysterectomy [ID: 1374862

INTRODUCTION: Postoperative organ space surgical site infection (oSSI), commonly referred to as pelvic abscess, is a clinically impactful complication after hysterectomy. Although more common in open hysterectomies, oSSIs occur in minimally invasive hysterectomy (MIH), contributing to morbidity. In the current study, we evaluate perioperative factors contributing to development of oSSIs in patients undergoing MIH. METHODS: From 2016 to 2022, a multicenter retrospective analysis of patients undergoing MIH was conducted. Patient characteristics, preexisting conditions, surgical history, intraoperative factors, and type of MIH were evaluated to determine factors contributing to the development of oSSI. RESULTS: One thousand one hundred eighty-nine patients underwent MIH. 28 patient (2.4%) developed oSSI. There was no difference in age or body mass index between groups (P>.05) and no difference in the incidence of oSSI based on type of MIH (P=.832). Patients with endometriosis were more likely to develop oSSI (4.9% versus 2.0%, P=.045, odds ratio [OR] 2.49, 95% CI 1.98–6.25). A diagnosis of cancer did not affect oSSI (3.9% versus 2.1%, P=.162, OR 1.90, 95% CI 0.76–4.78). History of diabetes, hypertension, cesarean delivery, prior laparoscopy, prior laparotomy, smoking, or obesity did not affect the incidence of oSSI (P<.05). Patients developing oSSI had a greater mean intraoperative estimated blood loss (EBL) (233.55 cc versus 94.3 cc, P<.001), greater mean length of stay (LOS) (2.4 versus 0.9 days, P<.001), higher incidence of post-operative ileus (15.8% versus 0.7%, P<.001) and blood transfusion (34.6% versus 1.0%, P<.001). CONCLUSION: Development of oSSI is associated with preexisting endometriosis and greater intraoperative EBL. Development of oSSI was associated with greater LOS, postoperative ileus, and blood transfusions. Attention to hemostasis may reduce rates of oSSI.

Perioperative continuous infusions of factor VIII versus factor IX for patients with hemophilia A or B undergoing major surgery.

Continuous factor VIII (FVIII) or factor IX (FIX) infusions are commonly used for patients with hemophilia A (HA) or B (HB) undergoing surgery to secure perioperative hemostasis. To describe differences between the initial recovery and subsequent FIX and FVIII levels, and describe clinical outcomes among HB and HA patients receiving perioperative continuous infusion (CI) of recombinant FVIII and FIX concentrates. Retrospective chart review was conducted on 8 consecutive patients with HB and 7 consecutive patients with HA who underwent major surgery between 2014 and 2018 and received continuous infusions of standard half-life factor concentrate. Median initial bolus dose per kilogram was higher for HB compared to HA patients [90.8 (IQR 78.0-98.7) vs. 52.1 (IQR 48.6-55.6) IU/kg], while initial CI dose-rates were similar [4.3 (IQR 3.8-4.6) vs. 4.2 (IQR 3.8-4.4) IU/kg/h]. Median post-bolus recovery was higher for FVIII compared to FIX [1.70 (IQR 1.23-1.75) vs. 0.88 (IQR 0.75-1.00) IU/mL]. Median factor levels also were higher for FVIII on post-operative days 1 to 3. HB patients had greater mean intraoperative estimated blood loss [285.7 (range 0-1000) vs. 142.8 (range 0-400) mL] and longer median length of hospital stay [9 (IQR 8-12) vs. 5 (IQR 4-6.5) days]. Our initial evidence suggests greater in vivo yield of rFVIII compared to rFIX in the perioperative setting. We identified poorer clinical outcomes in this small cohort of perioperative HB patients indicating that they may benefit from a higher CI rate for adequate surgical hemostatic coverage.

S2-Alar-Iliac Screw Fixation versus Iliac Screw Fixation in the Treatment of Sacral Fractures

Purpose To compare the short-term therapeutic effects of S2-alar-iliac (S2AI) screw fixation and iliac screw fixation techniques in managing sacral fractures. Methods From September 2015 to May 2020, 42 patients with sacral fractures who underwent lumbopelvic fixation by a single surgeon were analyzed. The patients were divided into the S2AI screw group (19 patients) and the iliac screw group (23 patients). Operative data, reduction quality, postoperative complications, and functional outcomes were evaluated. Results The incidence of unplanned reoperation was significantly different between patients treated with S2AI screws than in those treated with iliac screws (0 versus 6, p = 0.02). The mean intraoperative estimated blood loss was 405.26 ± 229.67 mL in the S2AI screw group and 539.13 ± 246.32 mL in the iliac screw group (P = 0.08). No significant difference was observed in either group regarding the quality of reduction, functional outcome, or low back pain. The reduction quality based on the Matta criteria and excellent/good outcomes were 21/2 in the iliac screw group and 17/2 in the S2AI screw group. The functional outcomes based on the Majeed score and excellent/good/fair outcomes were 17/3/3 in the iliac screw group and 17/1/1 in the S2AI screw group. No complications, including implant breakage, loosening of the implant, or loss of reduction were found in either group during follow-up. Conclusion Both S2AI screws and iliac screws were effective in the treatment of sacral fractures. The use of S2AI screws, however, was independently associated with fewer unplanned reoperations for surgical site infection, wound dehiscence, and symptoms of screw protrusion than the use of iliac screws.

Blood Loss and Transfusion in a Pediatric Scoliosis Surgery Cohort in the Antifibrinolytic Era.

Children and adolescents undergoing posterior spinal fusion for scoliosis experience high rates of bleeding and blood product transfusion. Antifibrinolytic therapy is one key strategy to decrease blood loss and transfusion in pediatric scoliosis surgery. Here we review 172 pediatric scoliosis patients (birth to 21 y) who underwent posterior spinal fusion at our institution from 2017 to 2018. We reported rates of blood loss and transfusion, compared patients receiving tranexamic acid to a ε-aminocaproic acid, and evaluated antifibrinolytic agent and laboratory parameters as predictors of blood loss and transfusion. Intraoperatively, 62% received tranexamic acid and 38% received ε-aminocaproic acid. Overall, blood loss (mean intraoperative estimated blood loss=14.9±9.7 mL/kg, 22% with clinically significant blood loss [>20 mL/kg], and mean calculated hemoglobin mass loss=175.9±70.1 g) and transfusion rates (15% with intraoperative allogeneic red blood cell transfusion and mean intraoperative allogeneic red blood cell transfusion volume=12.5±7.1 mL/kg) were similar to previous cohorts studying intraoperative antifibrinolytics. There was no difference in intraoperative estimated blood loss, clinically significant blood loss, calculated hemoglobin mass loss, or transfusion rates between the antifibrinolytic groups. Antifibrinolytic choice was not predictive of blood loss or transfusion. Routine hematologic laboratory parameters and antifibrinolytic choice were insufficient to predict blood loss or other outcomes. Future prospective laboratory-based studies may provide a more comprehensive model of surgical-induced coagulopathy in scoliosis surgery and provide a better tool for predicting blood loss and improving outcomes.

Comparison of Minimally Invasive Lateral Lumbar Interbody Fusion, Minimally Invasive Lateral Lumbar Interbody Fusion, and Open Posterior Lumbar Interbody Fusion in the Treatment of Single-Level Spondylolisthesis of L4-L5

To compare the outcomes of minimally invasive lateral lumbar interbody fusion (LLIF) with minimally invasive transforaminal lumbar interbody fusion (TLIF) and conventional open posterior lumbar interbody fusion (PLIF) for treating single-level spondylolisthesis at L4-L5. The patients underwent minimally invasive LLIF (n= 18), minimally invasive TLIF (n= 17), and conventional open PLIF (n= 20) for spondylolisthesis at L4-L5. Reduction of slippage, improvement in segmental lordosis, and restoration of foraminal height were measured. Perioperative parameters such as blood loss and operation time and clinical outcomes such as visual analog scale score and Oswestry Disability Index were compared. Compared with the open PLIF group, the minimally invasive LLIF group showed greater restoration of mean foraminal height, significantly smaller mean intraoperative estimated blood loss, and less mean hemoglobin reduction on the third day postoperatively. Compared with the minimally invasive TLIF group, the minimally invasive LLIF group showed greater restoration of mean segmental lordosis. The minimally invasive LLIF group showed a significantly shorter mean time to start walking after surgery compared with the conventional open PLIF and minimally invasive TLIF groups. However, compared with the minimally invasive TLIF group, the minimally invasive LLIF group showed a significantly longer mean operating time. Clinical outcomes were not statistically different among the 3 groups. In the treatment of spondylolisthesis of L4-L5, minimally invasive LLIF provided an effective surgical alternative to minimally invasive TLIF or conventional open PLIF, with the advantages of less blood loss, the faster start of postoperative walking, and comparable improvement in radiologic parameters.

Postembolization Change in Magnetic Resonance Imaging Contrast Enhancement of Meningiomas Is a Better Predictor of Intraoperative Blood Loss Than Angiography

Preoperative embolization of meningiomas to reduce tumor vascularity and intraoperative blood loss remains controversial. Incomplete devascularization on angiography is not significantly correlated with intraoperative estimated blood loss (EBL). Magnetic resonance imaging (MRI) may provide a better assessment of devascularization and prediction of EBL. We retrospectively analyzed patients undergoing preoperative embolization for intracranial meningiomas. Cohorts based on postembolization devascularization (>50% vs. ≤50%) were compared. Of 84 patients with meningioma undergoing preoperative embolization, 35 (42%) had a postembolization MRI before resection and met study inclusion criteria. The mean tumor diameter was 4.9 ± 1.3 cm, and mean intraoperative EBL was 576 ± 341 mL. Compared with MRI, angiography overestimated devascularization in 22 patients (63%). Using pre- versus postembolization MRIs, 17 (49%) patients had a >50% decrease in enhancement, which was associated with lower mean intraoperative blood loss (444± 255 mL) compared with 17 patients with ≤50% devascularization (700 ± 374 mL) (P= 0.03). On angiography, the 22 (63%) patients who demonstrated >50% devascularization during embolization did not statistically differ in intraoperative EBL when compared with 13 (37%) patients with <50% angiographic devascularization. Patients with a ≤50% decrease in contrast enhancement onpostembolization MRI were 9 times more likely to lose >500 mL blood intraoperatively during resection (95% confidence interval 1.6-54, P= 0.01). Postembolization contrast-enhanced MRI is a better predictor of intraoperative blood loss during meningioma resection than postembolization angiography, which overestimates the degree of embolic devascularization. Postembolization preoperative MRI is warranted for optimal patient management.

121. Machine-vision image guided surgery (MvIGS): an intraoperative and radiation-free spine navigation system workflow analysis

BACKGROUND CONTEXT A worldwide survey conducted in 2013 reported that 78% of surgeons utilize 2D fluoroscopy during spine surgery. By comparison, and despite improved accuracy, computer-assisted spine navigation systems have lagged behind, largely due to increased costs, prolonged operative times and cumbersome surgical equipment. However, in recent years, computer-assisted spine navigation systems have grown in popularity as a result of decreasing costs and advancements in their user friendliness, thus improving integration into the surgical workflow. In an effort to address the growing concerns of current computer-assisted spine navigation systems, an emergent technology has been developed that does not require intraoperative ionizing radiation exposure. In addition to sparing the patient and surgeon to radiation exposure, this new spine navigation system, named the Machine-vision Image Guided Surgery (MvIGS) (7D Surgical, Toronto, Canada) system, is also projected to seamlessly integrate and therefore not contribute to prolonged operative times. By use of proprietary technology, localizing reference images are generated in a matter of seconds, as opposed to minutes, thus mitigating the disturbance to normal surgeon-defined workflow while maintaining accuracy. PURPOSE The purpose of this study is to prospectively compare clinical outcomes between the MvIGS spine navigation system to conventional 2D fluoroscopy in patients requiring posterior instrumentation in spine surgery. STUDY DESIGN/SETTING Prospective, single-center consecutive series. PATIENT SAMPLE Patients undergoing single- and multilevel posterior spine fusion surgery with pedicle screw instrumentation. OUTCOME MEASURES Our primary outcome measure is operative time. Secondary outcomes include demographic characteristics, intraoperative parameters and radiographic measurements including total exposure time (TET) and cumulative radiation dose (mGy). METHODS Radiographic and intraoperative data were collected from the first 26 patients enrolled in a large single-center, randomized prospective study comparatively evaluating 2D fluoroscopy to 3D MvIGS spine navigation in single and multilevel posterior spine fusion surgery. Intraoperative parameters assessed include mean operative time, estimated blood loss (EBL), total exposure time (TET) as measured in time (secs), and cumulative radiation dose (mGy) emitted by 2D fluoroscopy. Incidence of intraoperative complications, including dural tears or perioperative new/worsening neurological deficits, as well as mean length of hospital stay (LOS), were also collected. In patients undergoing circumferential spine surgery, only data pertaining to posterior instrumentation were collected. RESULTS Over 100 screws were implanted into 26 patients, 12 male and 14 female, with a mean age and BMI of 60.4 years and 29.8, respectively. Mean operative time between 3D and 2D imaging was 236 and 251 minutes, respectively. No significant difference in total exposure time (seconds) and cumulative radiation dose (mGy) were recorded with 3D navigation exhibiting an average of 27.4 and 14.3 respectively, compared to 2D's 28.8 and 16.1, respectively (p=1.0). Fifty-six percent (56%) of cases were multilevel fusion procedures, with nearly 90% involving the L4-5 vertebral segment. Mean intraoperative EBL and length of hospital stay were 390 mL and 3.5 days, respectively, with no significant difference between treatment groups. No new neurological deficits or complications were recorded. CONCLUSIONS Use of navigation systems in spine surgery is often cumbersome and time consuming, frequently disrupting surgeon workflow and prolonging operative times. Results from our cohort analysis demonstrate no significant difference in operative times between groups, indicating minimal workflow disruption. We believe two predominant theories as to why the MvIGS spine navigation system has resulted in minimal workflow disturbance. The integration of the navigation camera into the surgical light eliminates the need to stop surgery, drape and position supplemental surgical equipment, thereby allowing for continuous access to the surgical field. Secondly, and unique to the MvIGS system, the reference clamp can be repositioned and re-registration images completed within 20 seconds. This combination allows for seamless clinical applicability and reverses many of the well-documented drawbacks of preceding navigation systems. We believe we are the first to report on the clinical application of this radiation-free MvIGS technology in spine surgery. FDA DEVICE/DRUG STATUS Machine-Vision Image Guided Surgery (MvIGS) (Approved for this indication).

Robot assisted radical cystectomy with totally intracorporeal urinary diversion: initial, single-surgeon's experience after a modified modular training.

To report the perioperative and early functional outcomes of patients undergoing Robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion performed by a single surgeon after a modified modular training. The surgeon (A.P.) attained a 30-days modified modular training at a referring Center mentored by a worldwide-recognized robotic surgeon (P.W.). The training program consisted of: 1) e-learning based on 10 hours of theoretical lessons made by the mentor; 2) video-session concerning the different steps of the procedure, 3) step-by-step in vivo modular training. Demographics, intraoperative data and post-operative complications were recorded for each patient. Twenty-four consecutive patients were prospectively evaluated. Median age was 68.5 years (IQR 59-75). Thirteen (54.2%) and 11 (45.8%) patients received RARC with orthotopic neobladder (ONB) and ileal conduit (IC), respectively. Overall mean (±SD) operative time was 392 (± 34.8) minutes. The median number of lymph node retrieved was 30 (IQR 24-42), the mean intraoperative estimated blood loss (EBL) was 403 mL (±60) with average hospitalization of 7.8 days (±2.2). All procedures were completed successfully without open conversion. A statistically significant difference in terms of overall operative time (OT) and urinary diversion operative time (UDOT) was found in favor of IC group compared to ONB group (P=0.002). Overall complication rate was 33%, 7 out of 9 (88%) were graded as minor (Clavien 1-2). Two (22%) major complications (Clavien 3-5) occurred solely on ONB group. Robot-assisted radical cystectomy with totally intracorporeal urinary diversion is a challenging procedure with a steep learning curve. An adequate modular training with an experienced mentor and a skilled robotic team could be essential to reach these optimal results. Further studies investigating the impact of modular learning curve and a dedicated menthorship on operative and functional outcomes after RARC are needed.

To Ligate or Not to Ligate: Comparing Outcomes in Cesarean Hysterectomy With or Without Hypogastric Artery Ligation [29O

INTRODUCTION: To determine if hypogastric artery ligation during cesarean hysterectomy (Chyst) for patients with invasive placentas results in less blood loss and transfusion requirements. METHODS: Retrospective review of consecutive patients with invasive placenta who underwent Chyst at one institution between 1/2011 until 5/2016 was performed. Patient characteristics, surgical technique, laboratory parameters and patient outcomes were reviewed. RESULTS: A total of 35 patients (median age 35 years range: 22-42 years) were identified. Mean gestation age at Chyst was 34 weeks ± 3 weeks and 6 days. Thirteen of 35 patients underwent hypogastric artery ligation during Chyst. The mean intraoperative estimated blood loss (EBL) for the ligation group was 2,992 ± 2,420 mL and 2757 ± 2131 mL for the non-ligation group, p=0.77. The mean intraoperative transfusion requirements were 4.2 ± 4.7 units of packed red blood cells for the ligation group and 3.9 ± 6.5 units of packed red blood cells for the non-ligation group, p=0.91. The mean intraoperative time for the ligation group was 248 minutes ± 96 minutes and 190 minutes ± 70 minutes for the non-ligation group, p=0.09. The gestational age, length of post-operative intensive care unit hospital stay and total postoperative hospital stay were not significantly different between the two groups (p&gt;0.05). CONCLUSION: As hypogastric artery ligation becomes less prevalent in obstetrical and gynecological surgical curriculum, interventional radiology may assume a more prominent role for Chyst in patients with invasive placentas. Furthermore, hypogastric artery ligation during Chyst may not result in different intraoperative estimated blood loss or transfusion requirements.

The effect of surgeon experience on outcomes of surgery for adolescent idiopathic scoliosis.

Single-surgeon series investigating the learning curve involved in surgery for spinal deformity may be confounded by changes in technology and techniques. Our objective with this multicenter, prospective study was to present a cross-sectional analysis of the impact of surgeon experience on surgery for adolescent idiopathic scoliosis. All posterior-only surgical procedures for adolescent idiopathic scoliosis performed in the 2007 to 2008 academic year, with a minimum of two years of patient follow-up, were included. Two groups were created on the basis of surgeon experience: a young surgeons' group, which included patients of surgeons with less than five years of experience, and an experienced surgeons' group, which included patients of surgeons with five or more years of experience. Nine surgeons (four young and five experienced) operated on a total of one hundred and sixty-five patients with adolescent idiopathic scoliosis. The surgeons' experience ranged from less than one year to thirty-six years in practice. The two groups had similar preoperative curve-magnitude measurements, SRS-22 (Scoliosis Research Society-22) scores, and distribution by Lenke curve type. There were significant operative and postoperative differences. The young surgeons fused an average of 1.2 levels more than the experienced surgeons (p = 0.045). The mean intraoperative estimated blood loss (EBL) of the young surgeons' group was more than twice that of the experienced surgeons' group (2042 mL compared with 1013 mL; p < 0.001). The duration of surgery was 458 minutes for the young surgeons compared with 265 minutes for the experienced surgeons (p < 0.001). The overall SRS-22 scores were significantly worse in the young surgeons' group (a mean of 4.1 compared with 4.5; p = 0.001). The difference between groups was also significant for the domains of pain (p = 0.016), self-image (p = 0.008), and function (p < 0.001). Complication rates did not differ significantly between the groups. Operative results and health-related quality of life following surgery for adolescent idiopathic scoliosis were significantly and positively correlated with surgeon experience. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Modified transperitoneal laparoscopic radical prostatectomy : clinical study of 285 cases

Objective To evaluate the technique and clinical outcomes of modified transperitoneal laparoscopic radical prostatectomy. Methods A total of 285 patients received the operation with mean age of 67 years (50-76 years) from January 2008 to April 2012.Mean level of PSA was 15.7 μg/L (1.8 -50.0 μg/L),and mean prostatic volume was 44 ml (26 -74 ml). No lymph node or seminal vesicle involvement was found by CT or MR and radionuclide bone scan revealed no metastasis.271 cases were confirmed diagnosis by prostatic biopsy and 14 were detected through pathological studies of TURP specimens.Gleason score ranged from 6 to 8.14 cases were in clinical stage T1b,29 cases in T1c,214 cases in T2 and 28 cases in T3a.Transperitoneal approach and modified technique involving bladder neck dissection,nervesparing technique and vesicoureteral anastomosis were applied on patients. Results Mean operative time was 105 min (55 -150 min).Mean intraoperative estimated blood loss was 240 ml (50-800 ml).Rectal injures occurred in 2 cases and were repaired under laparoscopy.Drainage tube and urinary catheter were removed 48 -72 h and 5 -8 d postoperatively.Postoperative hospital stay was 7 d (5 - 11 d).Positive surgical margin was present in 58 patients.Mean follow-up time was 29 months (3 -50 months).Complete continence were found in 208 patients immediately after catheter removal.68 patient recovered continence within 3 months and 9 patients remained incontinence 3 months after surgery. Normal erection presented in 42 of the 57 cases with nerve-sparing. Conclusions Transperitoneal laparoscopic radical prostatectomy is safe and efficient.Higher efficiency and lower complication rate have been achieved through modified laparoscopic technique involving bladder neck dissection,nerve-sparing technique and vesicoureteral anastomosis. Key words: Prostatic neoplasms; Laparoscopy; Transperitoneal approach; Radical prostatectomy

A Study of the anatomy of the renal pedicle during retroperitoneoscopic nephrectomy

Objective To study the anatomical characteristics of the renal pedicle and its clinical application during retroperitoneoscopic nephrectomy.Methods The imaging, surgical video and clinical data of 278 cases undergoing retroperitoneoscopic nephrectomy between July 2007 and September 2009 were retrospectively analyzed. The renal pedicle was found located at the psoas and the medial arcuate ligament of the diaphragm for anatomic landmark before the gap of the psoas. A statistical analysis of the mean operative time, the mean time to look for the renal pedicle, the mean intraoperative estimated blood loss, the mean time to ambulation, the mean time to resuming oral intake, the mean postoperative hospital stay day and the rate of complications was performed.ResultsAll the operations were performed successfully, with no conversion to open and blood transfusion. The mean time to find the renal pedicle was (3.5 ± 1.3 ) min, the mean operative time was (95.6 ±23.8) min, the mean estimated blood loss was (72.4 ±27.5) ml, the mean time to resuming oral intake was (2.1 ±0.7) d, the mean time to ambulation was (1.8 ±0.9) d, the mean postoperative hospital stay was (8.5 ± 2.7 ) d.Conclusions During retroperitoneoscopic nephrectomy, the best anatomical space to look for the renal pedicle is the space before the psoas muscle. The exact location of the renal pedicle is under the diaphragm medial arcuate ligament about 2 - 4 cm, in the gap of the psoas muscle and the vena cava (abdominal aorta). Following this procedure could reduce the time to look for the renal pedicle, thus reducing operative time. Key words: Laparoscopy ; Nephrectomy; Anatomy; Retroperitoneoscopy

Anatomical path of intraperitoneal radical nephrectomy: clinical experience of 60 cases

To evaluate the safety and efficacy of intraperitoneal anatomical radical nephrectomy (IARN). A retrospective analysis was performed for 60 consecutive patients undergoing IARN at our hospital from March 2007 to December 2009. Various clinical parameters were collected and analyzed statistically. Sixty operations were performed successfully. There was neither conversion into open surgery nor blood transfusion. The mean operative time was (106 ± 23) min, mean intraoperative estimated blood loss (112 ± 37) ml, mean time of resuming oral intake (2.1 ± 0.7) d, mean time to ambulation (1.9 ± 1.1) d, mean postoperative analgesics (pethidine) dosage (65 ± 25) mg, average drainage volume 100 (50 - 300) ml, mean time of extracting drainage tube (3.6 ± 1.3) d and mean postoperative hospital stay (9.4 ± 2.1) d. IARN offers the advantages of distinct anatomical level, shorter operative time, less hemorrhage, less damage, faster postoperative recovery and a lower rate of complications.

Laparoscopic Dismembered Pyeloureteroplasty: A Single Institution's 3-Year Experience

To review our most recent experience with laparoscopic dismembered pyeloureteroplasty (LDP) as treatment for ureteropelvic junction (UPJ) obstruction. All patient charts from March 1, 2000, through March 1, 2003, were reviewed to identify individuals who had undergone LDP. Twenty-two consecutive procedures were performed on 21 patients. The average patient age was 37 years (range 6-77 years). Multiple data points were collected, including patient age, presenting symptoms, degree of hydronephrosis, presence of crossing vessels, operative time (cystoscopy, retrograde pyelography, stent placement, and LDP), estimated blood loss (EBL), length of hospital stay (time to discharge home after preoperative admission), parenteral analgesic use, complications, and results of follow-up imaging studies and symptoms (including an analog pain scale). Mean and range values for quantitative data are reported. Twelve right and ten left renal units were operated on; in 12 UPJs, a crossing vessel was causative of the obstruction. The mean operative time was 291 minutes (range 180-500 minutes) and the mean intraoperative EBL was 63 mL (range 20-100 mL). There were no conversions to open surgery. The mean hospital stay was 40 hours (range 24-120 hours). The average number of parenteral analgesic doses before conversion to oral narcotics was 5 (range 1-10). Three patients had successful pyelolithotomies at the time of reconstruction with a 100% stone-free rate on postoperative imaging studies. The average time of follow-up evaluation was 199 days (range 31-705 days). All patients either had serial ultrasound examinations, diuretic intravenous urograms, or both for follow-up evaluation, which demonstrated improvement in hydronephrosis and renal drainage. All patients with pain preoperatively had resolution of their symptoms postoperatively. There were no intraoperative complications, seven early postoperative complications (three urinary tract infections, two hospital readmissions for ileus, one urine leak, and one delayed hemorrhage, presumably from a trocar site). Laparoscopic dismembered pyeloureteroplasty is safe and effective and associated with minimal morbidity.

Transfusion-associated circulatory overload in orthopedic surgery patients: a multi-institutional study

Abstract Although recognized as a serious complication of hemotherapy, few data are available on the incidence of transfusion-associated circulatory overload (TACO). Detailed demographic and clinical information was obtained from records of 382 Medicare patients undergoing total hip or knee replacements (and receiving transfusions) from January 1992 to December 1993 at five Massachusetts hospitals. Seventy-eight percent of the patients were women with a mean age of 77 years. Thirty-two percent had co-morbidities including myocardial or coronary disease. Transfusion-related complications and comorbidities were identified and reviewed by transfusion experts. Patients were excluded from consideration if non-transfusion factors such as myocardial disease could have contributed to the development of acute pulmonary edema. Four (3 females, 1 male) patients (1.05%) developed TACO postoperatively. Mean age of these patients was 84 years (range, 75–101) versus 77 years for non-TACO. The mean intraoperative estimated blood loss was 375 mL. Each patient received only 1–2 units of red blood cells prior to onset of TACO, and in two cases only autologous blood was used. The mean positive fluid balance was 2,480 mL. The mean pretransfusion hematocrit prior to circulatory overload (CO) was 26.0 percent. symptoms were reversed with diuretics. Length of stay was significantly prolonged by these incidents. TACO is a frequent and serious event in an orthopedic surgical setting. It is associated with advanced age, increased health care costs, and may occur in the setting of modest transfusion volumes. The utilization of conservative transfusion criteria and fluid management in the perioperative setting may decrease the incidence of this complication in this population. Immunohematology 1996;12:87–89.