Need For Intraoperative Blood Transfusion Research Articles

Role of tranexamic acid in reducing peri-operative blood loss in open spine surgeries.

Spine surgeries are associated with significant blood loss due to the extensive soft tissue dissection, bony decompression, and prolonged surgical time. Excessive bleeding may require blood transfusions and thereby increase the risk of adverse transfusion reactions. Therefore, minimizing peri-operative bleeding is important for spine surgeons to reduce post-operative morbidity. Tranexamic acid (TXA) is a synthetic anti-fibrinolytic drug, which helps in reducing perioperative blood loss in major surgeries. The evidence on the efficacy of this agent in all manner of spine surgeries is not sufficient. Hence this study was conducted to determine the efficacy of TXA on perioperative blood loss in major spinal surgeries. In a prospective study, two groups of patients with similar surgical profiles who were posted for all manner of open spine surgeries were included. One group received one gram of intravenous TXA while the others did not. Intra- and post-operative assessments included noting levels of surgery, duration of surgery, assessment of blood loss, intra- and/or post- operative blood transfusion, and blood collected in surgical drain at the end of 24h. The intra-operative blood loss, frequency of intra-operative blood transfusion, post-operative Hemoglobin drop, and surgical drain output were found to be significantly lower in patients who received TXA. In spine surgeries, TXA was found to be effective in reducing intra-operative blood loss, need for intra-operative blood transfusion and post-operative Hb drop. Also, TXA had reduced surgical drain output significantly between the two groups.

Blood Transfusion Predictors in Cesarean Sections for Pregnancies With Placenta Accreta and Placenta Previa: A Monocentric Tertiary Experience.

Objective The objective of this study was to analyze the possible predictors of the need for intraoperative blood transfusion in cesarean sections for pregnancies with abnormal placentation. Methods This wasa retrospective study based on data from patients' electronic medical records. A total of 44 patients who were diagnosed as placenta previa or placenta accreta who delivered through cesarean section at King Fahad University Hospital,Al-Khobar,Saudi Arabia, from June 1997 to January 2021 were included in the study. Seventeen patients received intra-operative blood transfusion. The other 27 patients did not receive any blood transfusions and served as controls. Demographic data, antepartum profiles, and obstetric history were compared between the two groups. Univariate analysis and multivariate logistic regression were used to analyze the correlations between related risk factors and the need for intraoperative blood transfusion. Results Univariate analysis (χ2 test) has shown multiple factors that correlated significantly (p<0.05) with blood transfusion requirement. These factors include the presence of placenta accreta, general anesthesia, preoperative hematocrit < 33%, preoperative hemoglobin ≤ 10 g/dL, and preterm delivery at 35-36 weeks of gestation. None of these factors showed any statistical significance in multivariate analysis (logistic regression). Conclusion General anesthesia, placenta accreta, delivery at 35-36 weeks of gestation, and pre-operative anemia are possible risk factors for blood transfusion during cesarean sections for abnormal placentation. Identifying patients at increased risk is necessary to optimize pre-operative and intraoperative management.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

Acute social isolation and postoperative surgical outcomes. Lessons learned from COVID-19 pandemic.

During COVID-19 pandemic, hospitals changed visitation policy to limit the infection spread. We aimed to evaluate the impact of evolving visitation policy on short-term surgical outcomes. All adult patients who underwent colorectal surgery between January 1st, 2020, and May 12th, 2020, at our institution were included. Patients were divided into: before implementing the no visitor allowed policy (VA) or no visitor allowed policy (NVA) groups, based on the hospital admission date.. The primary outcomes were 30-day readmission rate and length of stay (LOS). A total of 439 patients were included. Of them, 128 (29.2%) patients had surgery during the NVA policy, and 311 (70.8%) patients underwent surgery during VA policy. Patients who had surgery during the NVA policy were more likely to have emergency surgery and a longer operation time. However, the other baseline characteristics, surgical approach, underlying disease, extent of resection, and the need for intraoperative blood transfusion were comparable between the two groups. There was no difference between both groups regarding the 30-day readmission rate (10.3% vs. 7.8% in the NVA group; P>0.05) and median LOS (4 days vs. 3 days in the NVA group; P>0.05). Restricting inpatient visitors for patients undergoing colorectal surgery was not associated with increased postoperative complications and readmission rates. LOS was similar between the two groups. This strategy can be safely implemented in cases of crisis. Further studies are needed to confirm these findings.

Perioperative Anemia, Gender, Blood Transfusion and Urine Output during Cardiopulmonary Bypass: Risk Factors for Acute K. Injury

Objective: The aim of current study was to find out the factors causing Acute Kidney Injury (AKI) in the postoperative period of cardiac surgery. This prospective study, Peri-operative Anemia, Urine Output, gender, need for Intra-operative blood transfusion were analyzed for association of AKI. Material and Method: The study was conducted at Cardiac Center, QAMC Bahawalpur from January, 2019 to June, 2021. A total of 180 patients who underwent cardiopulmonary bypass for IHD and Valve surgery were studied. CPB hemoglobin levels, Blood Transfusion in OR, Gender specificity, Peri-operative urine output (Group1 UO &lt;4ml/kg/hr: Group 2 UO &gt; 4ml/kg/hr) were correlated to establish their relationship in causing post-operative Acute Kidney Injury. The patients were divided into two groups one who had Acute Kidney Injury other who don’t. Results: Acute kidney injury developed in 20 out of 180 patients, current study showed insignificant relation between CPB time, X clamp time, Gender, Surgery type, MAP and Postoperative Acute Kidney Injury. Acute Kidney Injury was more associated with diabetes, need of blood transfusion, perioperative hemofiltration and reduced urine output. Conclusion: Current study showed that Acute Kidney injury is an avoidable complication if hemoglobin levels are kept above 8-9 gm/dl to ensure proper oxygen supply and need of Intraoperative hemofiltration and BT is reduced by reducing circuit length thus hemodilution and found a urine output less than 4 ml/kg/hr during cardiopulmonary bypass carries major risk for AKI. Keywords: AKI Acute Kidney injury CPB Cardiopulmonary bypass UO urine output MAP Mean Arterial Pressure

Perioperative risk of pancreatic head resection—nomogram-based prediction of severe postoperative complications as a decisional aid for clinical practice

PurposeTo develop nomograms for pre- and early-postoperative risk assessment of patients undergoing pancreatic head resection.MethodsClinical data from 956 patients were collected in a prospectively maintained database. A test (n = 772) and a validation cohort (n = 184) were randomly generated. Uni- and multi-variate analysis and nomogram construction were performed to predict severe postoperative complications (Clavien-Dindo Grades III–V) in the test cohort. External validation was performed with the validation cohort.ResultsWe identified ASA score, indication for surgery, body mass index (BMI), preoperative white blood cell (WBC) count, and preoperative alkaline phosphatase as preoperative factors associated with an increased perioperative risk for complications. Additionally to ASA score, BMI, indication for surgery, and the preoperative alkaline phosphatase, the following postoperative parameters were identified as risk factors in the early postoperative setting: the need for intraoperative blood transfusion, operation time, maximum WBC on postoperative day (POD) 1–3, and maximum serum amylase on POD 1–3. Two nomograms were developed on the basis of these risk factors and showed accurate risk estimation for severe postoperative complications (ROC-AUC-values for Grades III–V—preoperative nomogram: 0.673 (95%, CI: 0.626–0.721); postoperative nomogram: 0.734 (95%, CI: 0.691-0.778); each p ≤ 0.001). Validation yielded ROC-AUC-values for Grades III–V—preoperative nomogram of 0.676 (95%, CI: 0.586–0.766) and postoperative nomogram of 0.677 (95%, CI: 0.591–0.762); each p = 0.001.ConclusionEasy-to-use nomograms for risk estimation in the pre- and early-postoperative setting were developed. Accurate risk estimation can support the decisional process, especially for IPMN-patients with an increased perioperative risk.

Post-operative clinical outcomes and complications of posterior versus lateral approach for primary total hip arthroplasty: A retrospective cohort study

Objectives: Total hip arthroplasty (THA) is considered one of the therapeutic procedures frequently performed in orthopedic surgery. It is believed that the surgical approach could influence the clinical outcomes following THA. We performed a retrospective cohort study to compare the postoperative clinical outcomes and complications between the posterior approach (PA) and the lateral approach (LA) for primary THA. Methods: We enrolled patients who underwent primary THA through PA or LA. We sought to evaluate the postoperative complications including the need for intra- or postoperative blood transfusion, dislocation rate, and venous thromboembolism events, and the clinical outcomes, including length of hospital stay, operative time, and perioperative blood loss. Results: A total of 211 patients (71 patients in PA vs. 140 patients in LA) were deemed eligible to be included in this study. There was no significant difference between PA and LA in post-operative clinical outcomes concerning operative time, and perioperative blood loss except for the length of hospital stay (PA median = 6.0 days vs. LA median = 9.0 days; P &lt; 0.001) patients. After adjustment for the potential confounders, the length of hospital stay was found to be similar between the two groups (P = 0.06). Similarly, no difference was found between PA and LA in post-operative complications concerning the need for intra-operative blood transfusion, dislocation rate, and venous thromboembolism events except for the need for postoperative blood transfusion (RR = 1.82, 95% CI 1.16–2.87), which continued to be significantly higher in PA even after adjustment for the potential confounders (P ≤ 0.01). Conclusion: PA and LA herald similar outcomes for patients undergoing primary THA concerning the postoperative clinical outcomes and complications except for the need for post-operative blood transfusion.

Encouragement for Further Study of Tranexamic Acid Administration for Sacroiliac Joint Fusion Surgery.

TO THE EDITOR: We read with great interest the article by Huynh et al.regarding the association between tranexamic acid (TXA) and blood loss in patients undergoing surgical treatment for hip fracture (Huynh PAN, Miller M, Will R. Intravenous Tranexamic Acid Decreases Blood Transfusions and Blood Loss for Patients with Surgically Treated Hip Fractures. Geriatric Orthopedic Surg Rehabil. 2021). The authors illustrated, via retrospective chart review of 505 patients who were surgically treated for hip fractures, that patients administered TXA had statistically significant decreases in perioperative blood loss and reduced relative risk of transfusion. Huynh et al. reported no statistically significant increases in thromboembolic events in patients given TXA. Mechanistically, TXA is a synthetic anti-fibrinolytic that competitively inhibits the plasminogen activation pathway. By preventing activated plasmin from de-stabilizing the fibrin matrix, TXA promotes clot formation. Given the anti-fibrinolytic effects of TXA, concerns in the literature exist regarding its use being associated with increased risk for thromboembolic events. However, it is important to note the complication profile associated with TXA is minimal, as elucidated by Brown et al., specifically finding that no patients who were administered TXA perioperatively experienced a thromboembolic event (or at least, there were no reports of thromboembolism or any other adverse events). While administration of TXA may theoretically increase the risk for thrombosis, Brown et al. showed this does not seem to occur in spinal laminectomy and fusion with posterior instrumentation. Similarly, in a systematic review of the literature describing TXA use in intracranial tumor resection, this study revealed a statistically significant reduction in the need for intraoperative blood transfusion in patients administered TXA. Upon consideration of postoperative outcomes, no significant increase in complication rate was found. This evidence in the existing literature on TXA use in orthopedic, spinal, and cranial neurosurgery exemplifies the wide potential of TXA for reducing blood loss with minimal complications in surgical procedures, especially involving the craniospinal axis.

JUVENILE NASOPHARYNGEALANGIOFIBROMA: OUR EXPERIENCE AND LITERATURE REVIEW

ABSTRACT&#x0D; Introduction: Juvenile nasopharyngeal angiofibroma is a benign vasculartumor.It is commonly found in teen age males. Its site of origin is sphenopalatine foramen. Exact pathogenesis of angiofibroma is not known. It has predictable natural history and growth pattern. This tumor most often involves nasopharynx, nasal cavity, paranasal sinuses, pterygopalatine fossa and infratemporal fossa. It can also involve orbit and can spread intracranially. Its very important to diagnose this tumor very early on the basis of clinical examination and imaging. As early tumor confined to nose and sinuses can be removed exclusively with endoscope. It is very helpful to do angiography before surgery to ascertain itsblood supply and then embolization can be done to reduce intraoperative bleeding. Objective: To describe our experience of Juvenile Nasopharyngeal Angiofibroma cases in ENT Unit-I of Lahore General Hospital. Study Design: Descriptive Study with retrospective analysis after approval from Institutional Review Board (IRB) of LGH/PGMI/AMC Lahore. Methods: We studied 20 patients who underwent surgery in our department from October 2019 to October 2020. We analyzed following factors: age, gender, symptoms, staging, mode of surgery and need for intraoperative blood transfusion, hospital stay, complications and recurrences. Results: Range of patient’s age was 12 to 25 years. Eight patients underwent surgery with endoscope. Mean blood loss was about 400 ml and mean operating time was 140 minutes. All the cases were embolized preoperatively. Conclusion: Endoscopic surgery is a safe and effective method in early stage JNA patients. While patients with advance stage tumors should be managed with combined endoscopic and conventional open approaches.&#x0D; KEYWORDS: juvenile nasopharyngeal angiofibroma, JNA, endoscopic surgery&#x0D;

International multicentre propensity score-matched analysis comparing robotic versus laparoscopic right posterior sectionectomy.

Minimally invasive right posterior sectionectomy (RPS) is a technically challenging procedure. This study was designed to determine outcomes following robotic RPS (R-RPS) and laparoscopic RPS (L-RPS). An international multicentre retrospective analysis of patients undergoing R-RPS versus those who had purely L-RPS at 21 centres from 2010 to 2019 was performed. Patient demographics, perioperative parameters, and postoperative outcomes were analysed retrospectively from a central database. Propensity score matching (PSM) was performed, with analysis of 1 : 2 and 1 : 1 matched cohorts. Three-hundred and forty patients, including 96 who underwent R-RPS and 244 who had L-RPS, met the study criteria and were included. The median operating time was 295 minutes and there were 25 (7.4 per cent) open conversions. Ninety-seven (28.5 per cent) patients had cirrhosis and 56 (16.5 per cent) patients required blood transfusion. Overall postoperative morbidity rate was 22.1 per cent and major morbidity rate was 6.8 per cent. The median postoperative stay was 6 days. After 1 : 1 matching of 88 R-RPS and L-RPS patients, median (i.q.r.) blood loss (200 (100-400) versus 450 (200-900) ml, respectively; P < 0.001), major blood loss (> 500 ml; P = 0.001), need for intraoperative blood transfusion (10.2 versus 23.9 per cent, respectively; P = 0.014), and open conversion rate (2.3 versus 11.4 per cent, respectively; P = 0.016) were lower in the R-RPS group. Similar results were found in the 1 : 2 matched groups (66 R-RPS versus 132 L-RPS patients). R-RPS and L-RPS can be performed in expert centres with good outcomes in well selected patients. R-RPS was associated with reduced blood loss and lower open conversion rates than L-RPS.

Machine learning models to predict red blood cell transfusion in patients undergoing mitral valve surgery.

Red blood cell (RBC) transfusion therapy has been widely used in surgery, and has yielded excellent treatment outcomes. However, in some instances, the demand for RBC transfusion is assessed by doctors based on their experience. In this study, we use machine learning models to predict the need for RBC transfusion during mitral valve surgery to guide the surgeon's assessment of the patient's need for intraoperative blood transfusion. We retrospectively reviewed 698 cases of isolated mitral valve surgery with and without combined tricuspid valve operation. Seventy percent of the database was used as the training set and the remainder as the testing set for 13 machine learning algorithms to build a model to predict the need for intraoperative RBC transfusion. According to the characteristic value of model mining, we analyzed the risk-related factors to determine the main effects of variables influencing the outcome. A total of 166 patients of the cases considered had undergone intraoperative RBC transfusion (24.52%). Of the 13 machine learning algorithms, CatBoost delivered the best performance, with an AUC of 0.888 (95% CI: 0.845-0.909) in testing set. Further analysis using the CatBoost model revealed that hematocrit (<37.81%), age (>64 y), body weight (<59.92 kg), body mass index (BMI) (<22.56 kg/m2), hemoglobin (<122.6 g/L), type of surgery (median thoracotomy surgery), height (<160.61 cm), platelet (>194.12×109/L), RBC (<4.08×1012/L), and gender (female) were the main risk-related factors for RBC transfusion. A total of 204 patients were tested, 177 of whom were predicted accurately (86.8%). Machine learning models can be used to accurately predict the outcomes of RBC transfusion, and should be used to guide surgeons in clinical practice.

PORTAL AND ARTERIAL REPERFUSION DURING LIVER TRANSPLANT: A COMPARISON BETWEEN THE SIMULTANEOUS AND SEQUENTIAL TECHNIQUES

Introduction: A critical step in the liver transplantation procedure is the reperfusion of the liver graft after being connected to the circulatory system of the receptor. There are two possible techniques for the reperfusion: it may occur immediately after the portal vein anastomosis has been completed, with revascularization of the graft with blood from the portal system first, and then with arterial blood after the completion of the arterial anastomosis, in what is usually referred to as the sequential technique; or the reperfusion can occur only after both portal and arterial anastomosis have been completed, in what is referred to as the simultaneous technique. There is significant debate in the literature on whether one of these techniques offer advantages over the other, with studies pointing to a reduction of biliary complications with use of the simultaneous technique, while other studies failed to show any improvement. We present an analysis of 100 liver transplants performed using each technique, consisting in the largest single-center study on this subject performed so far. Materials and Methods: We analyzed 200 liver transplants performed on a tertiary Brazilian hospital during the 2014 to 2017 period, with 100 transplants using the sequential technique being performed immediately before 100 transplants using the simultaneous technique. All procedures used whole liver grafts procured from cadaveric donors. Statistical analysis was performed using Yates corrected Pearson’s chi-square for qualitative parameters and t test for quantitative parameters. Results: There was a significant difference in blood products transfusion between the two groups, with a mean of 1.11 units in the sequential perfusion (SeP) group, as opposed to 0.59 in the simultaneous perfusion (SiP) group (p=0.02). There was also a statistically significant difference in total procedure time, with an average of 398 minutes in the SeP group vs. 368 in the SiP group (p=0.0001); total ischemia time, with an average of 421 minutes in the SeP group vs. 472 minutes in the SiP group (p=0.002); and receptor age, with a mean of 51.1 years in the SeP group vs. 54.3 in the SiP group (p=0.03). No difference was found in mortality or biliary stenosis between the two groups. Discussion: While there was an increase in total ischemia time associated with SiP, due to the additional time in completing the arterial anastomosis before reperfusion, there was no negative impact in patient mortality or morbidity. Reduction in total operative time and intraoperative transfusion may be associated with quicker hemostasis and liver function in SiP. Conclusion: The use of the simultaneous reperfusion technique in liver transplant, while having no direct impact on patient mortality, may decrease total procedure time and need for intraoperative blood transfusion. The expected increase in total ischemia time with the use of the simultaneous technique does not appear to increase patient morbidity or mortality.

Management of iron deficiency anaemia by the preanaesthesia nurse with respect to perioperative transfusion rates.

To describe the prevalence of perioperative blood transfusion (BT) for patients with preoperative iron deficiency anaemia and undergoing major elective surgery, included in an intravenous iron protocol (IV Fe) led by the pre-anaesthesia nurse. Observational, descriptive, longitudinal and retrospective study in a population of patients undergoing major elective surgery, seen in anaesthesia nursing consultation in a tertiary hospital between April 2014 and January 2017. The patients with iron deficiency anaemia, included in the study, were included in a protocol of treatment with preoperative IV Fe. Fifty patients were studied. Twelve percent required a BT. A statistically significant association was observed between the need for intraoperative BT and the number of days between the first administration of IV Fe and date of surgery (P<.01) and also the number of days between the last administration of IV Fe and the surgical intervention (P=.04). The increase in haemoglobin was greater in patients who received more than one dose compared to those who received only one dose of 1,000mg (P<.01). In our study, we estimated an increase in haemoglobin greater than in other studies and a low administration rate of BT (12%). The role of the nurse is fundamental for the preselection of these patients.

Dexmedetomidine versus magnesium sulfate for induced hypotension during functional endoscopic sinus surgery: A randomized, double-blind study

Background: Bleeding during functional endoscopic sinus surgery (FESS) can compromise surgical field quality. Intraoperative controlled hypotension by various hypotensive agents can reduce blood loss and improves surgical field visibility with less need for intraoperative blood transfusions. This study compared the hypotensive effectiveness and safety of dexmedetomidine and magnesium sulfate in patients undergoing elective FESS. Patients and Methods: Sixty adult patients posted for elective FESS were randomly assigned to two groups. Group A received a loading dose of dexmedetomidine 1 μg/kg, followed by infusion of 1 μg/kg/h, and Group B received a loading dose of magnesium sulfate 40 mg/kg, followed by 15 mg/kg/h infusion. Surgical field quality, emergence time, sedation score, Visual Analog Scale score, recovery profile, and vital signs were recorded. Mean arterial pressure (MAP) was kept above 65 mmHg during induced hypotension. Results: Both the groups achieved the target MAP (65–70 mmHg) and improved the surgical field visibility with reduced blood loss. Hemodynamics was superior in the dexmedetomidine group with the additional advantage of postoperative conscious sedation and analgesia (P 0.05). Conclusions: Both dexmedetomidine and magnesium sulfate are safe agents for controlled hypotension for improving surgical field quality. Dexmedetomidine provides an additional benefit of reducing the analgesic requirements and providing postoperative sedation.

Adjunctive use of tranexamic acid to tourniquet in reducing haemorrhage during abdominal myomectomy - A randomized controlled trial

BackgroundUterine fibroids are the commonest tumour of the female genital tract; about one third are symptomatic and require management. The treatment of uterine fibroids may be medical, surgical, conservative or expectant. Myomectomy is the common surgical treatment option for women failing medical management and desiring to preserve fertility and/or their uterus. The tourniquet is shown to be effective in reducing blood loss during myomectomy and tranexamic to a less extent. However, the adjunctive use of tranexamic acid with tourniquet to further reduce blood loss has not been studied. AimThe aim of the study was to determine the efficacy of perioperative intravenous tranexamic acid in further reducing blood loss at abdominal myomectomy when used as an adjunct to tourniquet. MethodsThe study was a randomized double-blind controlled study involving women who underwent abdominal myomectomy. Participants were randomized to either tourniquet plus intravenous tranexamic acid or tourniquet plus placebo groups using simple random sampling. The primary outcomes were the intra-operative blood loss, post-operative haematocrit values and need for intra-operative blood transfusion. The data was analyzed using the SPSS software version 23.0 and p value < 0.05 was significant. ResultsThe mean intra-operative blood loss (998.72 ± 607.21 ml vs 907.25 ± 529.85 ml, p = 0.475), intra-operative blood transfusion rate (45% vs. 30%; p = 0.166) and mean unit of blood transfused (1.13 ± 1.64 vs. 0.75 ± 1.28; p = 0.256) were higher for tourniquet plus placebo group compared to tourniquet plus tranexamic acid group. The estimated blood loss per 100 g of fibroid removed was reduced significantly in the tranexamic acid plus tourniquet group (139.80 ± 2.28 ml vs 104.09 ± 1.97 ml; p = 0.001). Strength and limitations: The strength of the study include randomization and blinding. The limitations included non-uniformity of sizes and locations of fibroids, as well as the different surgeons with possibly different skills, techniques and experiences, though they were statistically not significant. ConclusionThe adjunctive use of tranexamic acid to tourniquet significantly further reduces intraoperative blood loss during abdominal myomectomy when compared to tourniquet alone. RecommendationsAdjunctive use of tranexamic acid is recommended for further reducing intra-operative blood loss during abdominal myomectomy.

Modified Uniportal Video-Assisted Thoracic Surgery Versus Three-Port Approach for Lung Nodule Biopsy in Pediatric Cancer Patients.

Uniportal video-assisted thoracic surgery (VATS) is gaining popularity among thoracic surgeons, but the limited space in the thorax of children makes uniportal VATS difficult to perform. The purpose of this study was to evaluate procedural and outcome differences between a modified uniportal VATS (MU-VATS) and three-port VATS (TP-VATS) for peripheral lung nodule biopsy in pediatric cancer patients. This is an Institutional Review Board-approved retrospective analysis of all consecutive MU-VATS and TP-VATS peripheral lung nodule biopsies performed at a single institution between June 2014 and December 2016. Patients with diffuse lung disease who underwent a lung biopsy were excluded. Over a 30-month period, 22 patients with a median age of 12 years (range, 7-21) underwent MU-VATS or TP-VATS for excisional biopsy of a peripheral lung nodule. MU-VATS lung biopsy was attempted in 11 patients and TP-VATS lung biopsy in the remaining 11. Both groups were comparable with regard to demographics, primary diagnosis, purpose of biopsy, and lung nodule location. MU-VATS demonstrated no difference when compared with TP-VATS lung biopsy in operative time (54 versus 62 min, P = .899), estimated blood loss (14 versus 15 mL, P = .587), pain score (2.8 versus 2.9, P = .717), and discharge day (1.3 versus 1.2 days, P = .572). No difference existed between groups with regard to conversion, need for intraoperative blood transfusion, and duration of chest tube. Complications including pneumothorax (n = 2) and subcutaneous emphysema (n = 1) were only seen in the TP-VATS group. MU-VATS can be safely utilized for biopsy of peripheral lung nodules in pediatric cancer patients without increasing procedural duration, hospitalization, pain scores, or need for intraoperative blood transfusion. Further studies need to evaluate the theoretical cosmetic advantage from a single surgical scar.

Predicting the trajectory of post-hepatectomy liver dysfunction (PHLD)

Objective: PHLD is an expected outcome with more extensive liver resections, and it remains a major cause of morbidity. Early recognition of severe cases may be beneficial. The International Study Group of Liver Surgery (ISGLS) consensus criteria for post-hepatectomy liver failure serve to identify individuals with significant liver dysfunction. However, because the diagnostic criteria comprise liver dysfunction persisting more than 4 days after hepatectomy, the ISGLS definition is of limited use to a clinician. Our objective was to identify factors that inform the clinician whether PHLD is likely to be accompanied by an adverse clinical course. Methods: Liver resections between 2006 and 2014 were retrospectively reviewed. Patients with bilirubin ≥40 μmol/L and/or prothrombin time ≥1.5 at any time after surgery were identified. Factors associated with severe complications, ICU admission and death were identified. Results: During the study period, 1010 liver resections were performed and 110 patients (10.9%) had PHLD. Of those, 76 (69%) met the ISGLS criteria for liver failure. Clavien-Dindo complication grades ≥4 (ICU admission or mortality) occurred in 25 patients (22.7%). Factors associated with those adverse outcomes included patient age (P=0.015), duration of surgery (P=0.030), estimated blood loss (P=0.010), and the need for intraoperative blood transfusions (P < 0.001). The extent of liver resection and presence of cirrhosis did not predict clinical trajectory. Conclusion: Intraoperative events leading to prolonged surgery and excessive blood loss had the greatest influence on the clinical trajectory of PHLD.

Chemotherapy-induced Sinusoidal Injury (CSI) score: a novel histologic assessment of chemotherapy-related hepatic sinusoidal injury in patients with colorectal liver metastasis

BackgroundPreoperative neoadjuvant therapy for colorectal liver metastases (CRLM) is increasing in use and can lead to chemotherapy-induced damage to sinusoidal integrity, namely sinusoidal obstruction syndrome (SOS). SOS has been associated with an increased need for intraoperative blood transfusions, increased length of hospitalization post-surgery, decreased tumor response, and a shorter overall survival after resection due to liver insufficiency. It is critical for clinicians and pathologists to be aware of this type of liver injury, and for pathologists to include the status of the background, non-neoplastic liver parenchyma in their pathology reports. In this study, expression of CD34 by sinusoidal endothelial cells (SECs), increased expression of smooth muscle actin (SMA) by hepatic stellate cells (HSCs), and aberrant expression of glutamine synthetase (GS) by noncentrizonal hepatocytes were semiquantitatively evaluated in liver resection or biopsy specimens from patients with CRLM to determine their diagnostic value for assessing chemotherapy-induced sinusoidal injury (CSI).MethodsThe expression of each marker was compared among 22 patients with CRLM with histologically evident SOS (SOS+) and 8 patients with CRLM who had not undergone chemotherapy. Each case was given a histologic grade using the sinusoidal obstruction syndrome index score (SOS-I) to assess the likelihood of SOS. Cases were also given an immunohistochemical grade using the total CSI score calculated as the sum of CD34, SMA, and GS scores.ResultsAbnormal staining patterns for CD34 and SMA were significantly more frequent and extensive in SOS+ cases than in the controls (81.8% vs. 25%, P < 0.01; 72.7% vs. 25%, P = 0.03). Aberrant GS expression in midzonal and periportal hepatocytes was only observed in SOS+ cases (31.8% vs. 0%), but this difference did not reach statistical significance. The CSI score was significantly higher in the SOS+ cases when compared to controls (P < 0.01), and was associated with a higher SOS histologic grade (P = 0.02).ConclusionsThe CSI score, calculated using an immunohistochemical panel consisting of CD34, SMA, and GS, may serve as an objective marker of chemotherapy-induced sinusoidal injury and could help diagnose this peculiar form of liver injury.

Utility of non-invasive haemoglobin monitoring in oncosurgery patients.

Background and Aims:Oncosurgeries may incur massive blood loss demanding frequent blood sampling to assess blood loss and the need for intraoperative blood transfusions. Accuracy of non-invasive spectrophotometric haemoglobin (hereafter to be referred as SpHb) monitoring has been studied in various perioperative settings. The intraoperative use of Radical-7®, Masimo Corp., (Radical-7®) for SpHb monitoring may be useful during cancer surgery. The aim of this study is to evaluate the intraoperative utility of SpHb monitoring by the Radical-7® to guide intraoperative transfusion in oncosurgeries.Methods:Fifty adult patients, undergoing oncosurgery with anticipated blood loss of more than 20% of blood volume, were selected. Continuous SpHb monitoring was performed intraoperatively and blood transfusion was based on SpHb values. Simultaneous laboratory haemoglobin (LabHb) samples were taken for validation. The accuracy of intraoperative blood transfusions based on SpHb was analysed using Error Grid Analysis. Paired measurements of SpHb and LabHb were compared using Bland–Altman plot analysis.Results:There were 66 paired data points for blood transfusion from fifty patients with a correlation of 73% (P < 0.001) between SpHb and LabHb. In the Bland–Altman analysis, the bias was − 0.313 g/dl with ~ 95% of values within the limits of agreement of 1.81 g/dl to −2.44 g/dl. In the Error Grid Analysis, most data points were in the least error zone (Zone A).Conclusion:The Radical-7® has the advantage of providing SpHb value continuously to take prompt decision regarding blood transfusion intraoperatively.

Does temproray bilateral balloon occlusion of the common iliac arteries reduce the need for intra-operative blood transfusion in cases of placenta accretism?

Bilateral balloon occlusion has been employed as a prophylactic measure in cases of placenta accretism prior to caesarean section with the aim of reducing blood loss and its associated morbidity/mortality. There is however no clear consensus on its efficacy in the current literature. The objective of this study was to assess the efficacy of bilateral balloon occlusion of the common iliac arteries (CIA) in reducing intra-operative morbidity in cases of placenta accretism. The databases of the pathology department and radiology interventional suite were reviewed over a nine year period. Fifty-two cases of confirmed placental accretism who underwent caesarean section with or without hysterectomy were identified and divided into two groups. Twenty-five cases had temporary occlusion of the common iliac arteries (CIA) during delivery and these were considered the study group. The reminder 27 cases did not have temporary occlusion of the CIA and were considered the control group. The two groups were compared based on gravidity, age group, post-operative haemoglobin, drop in haemoglobin, estimated blood loss (EBL), transfusion requirement and the histopathological sub-types of placenta accretism. There was no statistically difference between the study and the control groups regarding EBL, post-operative haemoglobin drop, transfusion requirement or in the placenta accretism histopathological subtype. Two cases in the study group had acute thromboembolic complications. Both groups had a single patient requiring a massive intra-operative transfusion. Our study was not able to detect a significant difference in blood loss or blood product requirement between patients who underwent CIA balloon in the setting of caesarean section for placenta accreta. This remains a challenging scenario requiring a multidisciplinary approach.