Blood Transfusion In Surgery Research Articles

Endoscopic ultrasound-guided gold fiducial marker placement for intraoperative identification of insulinoma

Insulinomas are the most common functioning pancreatic neuroendocrine neoplasm, comprising 30%–45% of these tumors. Although laparoscopic resection is safe, minimally invasive, and is associated with shorter length of hospital stay, tumor localization at surgery can be challenging. We describe endoscopic ultrasound (EUS)-guided fiducial placement as a new technique for intraoperative localization of pancreatic insulinoma. A 36-year-old woman with episodes of confusion that resolved with intake of glucose and whose laboratory tests were suggestive of insulinoma was referred for laparoscopic distal pancreatectomy. Linear-array EUS (GF-UCT 240; Olympus Corp., Center Valley, Pennsylvania, USA) confirmed a tail mass (Fig.1). After retracting the stylet of the fine-needle aspiration (FNA) needle (Expect 19-gauge Flex needle; Boston Scientific Corp., Natick, Massachusetts, USA) by 2cm, one gold fiducial (3 × 0.8mm; Best Medical International, Springfield, Virginia, USA) was back-loaded into the lumen of the needle and sealed with bone wax. At EUS, the fiducials were deployed within the tumor by advancing the stylet forward (Fig.2). Overall, two fiducials were deployed (Fig.3), and a preoperative computed tomography (CT) scan confirmed their position. At laparoscopy, the fiducials were identified using cross-table fluoroscopy (Fig.4), and distal pancreatectomy with splenectomy was performed. A frozen section confirmed negative tumor margins, and the explant specimen revealed the tumor with fiducials in place (Fig.5). Final pathological analysis revealed T1 N0 grade II pancreatic neuroendocrine neoplasm (Fig.6). Fig.1 Linear-array endoscopic ultrasound (EUS) image of the isoechoic mass lesion in the tail of pancreas, superior to the left kidney. Fig.2 Fluoroscopic image showing the linear-array echoendoscope with the 19-gauge fine-needle aspiration (FNA) needle and the first fiducial. Fig.3 Endoscopic ultrasound (EUS) image showing the markers within the lesion casting an acoustic shadow (arrow). Fig.4 Intraoperative fluoroscopic image with the stapler gun in place. The two fiducial markers can be easily visualized. Fig.5 Postoperative specimen of the pancreas, showing the fiducial marker within the lesion. Fig.6 Postoperative histological specimen showing uniform sheets of polyhedral cells with hyperchromatic nuclei and abundant eosinophilic cytoplasm, consistent with a neuroendocrine neoplasm (hematoxylin and eosin stain, ×40). Preoperative injection of India ink [1] or indocyanine green [2] under EUS guidance was developed to facilitate quick tumor localization and to decrease operative time and blood transfusion requirements [3]. However, the disadvantages of dyes include peritonitis, infection, allergic reactions, and reabsorption within tissue planes [4]. In this report, we have described the use of fiducials as an alternative technique for this indication. The fiducials are inexpensive ($80 for five fiducials), easy to deploy, can be identified readily using fluoroscopy or intraoperative ultrasound, and (unlike dyes) do not extravasate into surrounding tissue. Endoscopy_UCTN_Code_TTT_1AS_2AD

CT-guided deep inferior epigastric perforator (DIEP) flap localization — Better for the patient, the surgeon, and the hospital

To define the clinical benefits to the patient of preoperative imaging planning for deep inferior epigastric perforator (DIEP) flap reconstruction. Since 2009 computed tomography angiography (CTA) has been provided for the preoperative planning of DIEP flap breast reconstruction in the largest plastic surgery unit in southeast England. In a retrospective, cohort-control study the outcomes of 100 consecutive patients who underwent preoperative CTA planning were compared with a closely-matched control group who underwent ultrasound planning only. The cohorts were evaluated for operative duration, mean operative blood loss and transfusion requirement, morbidity and flap or donor-site complications. There were statistically significant improvements in mean operative duration (p < 0.05), intra-operative blood loss (p < 0.05), shorter mean inpatient stay (p < 0.05) for the CTA planning versus the ultrasound planning of DIEP flap reconstruction. Statistically significant benefits were demonstrated in key aspects of the surgical procedure following CTA-guided planning. The implications of these benefits are profound in terms of pure healthcare cost benefits.

A kick in the shins: The financial impact of uncontrolled warfarin use in pre-tibial haematomas

Warfarin is increasingly prescribed in the elderly population for a number of medical conditions. Pre-tibial haematomas are a common cause of morbidity in this group. The aim of the study was to identify the proficiency of INR monitoring at a primary care level in correlation with their recommended INR range and to study the treatment outcome in this group.A retrospective single-centre study of patients diagnosed with pre-tibial haematomas was conducted over a two-year period. Length of hospital stay, time delay until operative intervention, blood transfusion and warfarin reversal requirements, social care input and cost to the NHS were considered.A total of 62 patients were admitted with pre-tibial haematomas of which 20 were on Warfarin. Females were predominantly more affected (5.6:1). The mechanism of injury was as a result of minor trauma. The mean INR level was 3.8 with a standard deviation of 3.1. Mean length of hospital stay was 11 days with a standard deviation of 13.6. Nine patients required skin grafting. Average cost for the acute episode was £3500 per patient.INR levels were significantly outwith the target range causing substantial patient morbidity and imposing a significant financial burden on the NHS. Tighter regulation at a primary care level should help reduce this risk.

Prognostic factors in pelvic exenteration for gynecological malignancies

ObjectivesAnalyze morbidity, mortality and prognostic factors after pelvic exenteration (PE) for gynecological malignancies. MethodsWe reviewed a series of 107 individuals who underwent PE at A.C. Camargo Cancer Hospital from August 1982 to September 2010. ResultsMedian age was 56.4 years. Primary tumor sites were uterine cervix in 73 cases (68.2%); vaginal, 10 (9.3%); endometrial, 14 (13.1%); vulvar, 7 (6.5%); and uterine sarcomas, 3 (2.8%). Median tumor size was 5.5 cm. Total PE was performed in 56 cases (52.3%), anterior in 31 (29.9%), posterior in 10 (9.3%) and lateral extended in 10. Median operation time, blood transfusion and hospital stay length were 420 min (range: 180–780), 900 ml (range: 300–4500) and 13 days (range: 4–79), respectively. There was no intra-operative death. Fifty-seven (53.3%) and 48 (44.8%) patients had early and late complications, respectively. Five-year progression free survival (PFS), overall survival (OS) and cancer specific survival (CSS) were 35.8%, 27.4% and 41.1%, respectively. Endometrial cancer had better 5-year OS (64.3%) than cervical cancer (23.1%). Lymph node metastasis negatively impacted PFS, CSS and OS. Presence of perineural invasion negatively impacted PFS and CSS. No variable retained the risk of recurrence or death in the multivariate analysis. ConclusionsPE has acceptable morbidity and mortality and may be the only method that can offer long-term survival in highly selected patients.

Profile of Oral Squamous Cell Cancer in a Tertiary Level Medical College Hospital: A 10 Yr Study

To know the clinical and epidemiological characteristics & management strategies for the patients who underwent surgery for oral Squamous Cell Cancer (SCC) in a medical college hospital. Data pertaining to clinico-epidemiological factors & surgical management for oral cancer were analyzed in patients admitted to a tertiary level medical college hospital. Records of 139 patients admitted over a period of 10years (January 1998 to December 2007) were used for data analysis. Only patients with complete records were included in the analysis. M: F ratio was 2.2:1 with average age of patients being 50.4years. Tobacco chewing & smoking were major predisposing factors identified. Oral ulcer was the most common symptom while buccal mucosa, tongue & lower alveolus were three most common primary tumor sites. Majority of tumors were stage IV at presentation (52%). Wide excision of tumor was done in 46% of cases while in 54% cases commando procedure was done. Reconstruction after either commando or wide excision was done in half of the patients. Pectoralis major myocutaneous (PMMC) flap was used in majority of cases for reconstruction. Neck dissection was done in 67% patients. Majority (85%) of these were radical neck dissection (RND). Per operative blood transfusions were required in 64% patients while 19% patients needed post operative transfusion. Post operative complications were noted in 34% of the patients. Of these majority were related to wound infection & orocutaneous fistula formation. Hospital stay varied from 7 to 105days with the mean duration of 30days. Two year follow up revealed a recurrence rate of 36%. Majority of the patients presented at an advanced stage due to self as well as professional delay in diagnosis. This leads to difficulty in resection of the primary tumor as well as reconstruction of the defect. A higher rate of recurrence after surgery is also seen. Post operative complications increase the morbidity which is reflected by an increase in the hospital stay (19days Vs 46days).

Feasibility of holmium laser enucleation of the prostate (HoLEP) for recurrent/residual benign prostatic hyperplasia (BPH)

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? The major advantage of holmium laser enucleation of the prostate (HoLEP) depends on the ability to use the native anatomical plane between the prostate adenoma and surgical capsule, peeling each prostatic lobe from the capsule. HoLEP is associated with less catheterisation time, hospital stay and blood loss than transurethral resection of the prostate (TURP) or open prostatectomy. Urodynamic relief of obstruction has been reported to be better with HoLEP than TURP. However, surgical treatment of recurrent prostatic obstruction after previous transurethral surgery for symptomatic benign prostatic hyperplasia is more challenging because of loss of anatomical landmarks resulting in either incomplete removal or incontinence. HoLEP for recurrent symptoms due to residual or re-growing prostatic adenoma seems to be as safe, feasible and efficient as HoLEP for de novo cases. The surgical plane between the adenoma and the surgical capsule was still accessible resulting in a durable long-term outcome with minimal side-effects. Previous transurethral prostatic surgery is not a contraindication for HoLEP. • To assess the technical feasibility, functional outcome and morbidity of holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia (BPH) in patients with previous transurethral prostate surgery. 'Redo' surgery for recurrent or residual BPH poses a technical challenge with uncertain outcome as a result of disturbed anatomical landmarks with no clear surgical limits. • We retrospectively reviewed 1054 patients who underwent HoLEP for symptomatic BPH. • Patients were stratified into two groups, group-I with no previous prostate surgery or primary-HoLEP (978 patients) and group-II with history of previous prostate surgery or secondary-HoLEP (76). • All patients' variables as well as follow-up data were assessed and compared. • There were no significant differences in baseline criteria between the two groups (P > 0.05). • In group-II, HoLEP was done after a median (range) of 66 (13-121) months from previous prostate surgeries, including transurethral resection of the prostate (48 patients), HoLEP (eight), transurethral incision of the prostate (nine), photoselective vaporization of the prostate (four) and other procedures (seven). • In both groups, routine HoLEP technique was adopted, the plane of enucleation could be identified without extra difficulty. However, more energy per gram of prostate tissue was needed in group-II (P < 0.05). • Operative auxiliary procedures were indicated in 1.9% of group-I, and 1.3% of group-II (P > 0.05). There were no operative complications or blood transfusion in group-II. The mean hospital stay and catheter time was similar in both groups. Early and late postoperative complications were not statistically different (P > 0.05). • At 1 month the mean maximum urinary flow rate (Q(max) ) was 22.3 and 18.8 mL/s, postvoid residual urine volume (PVR) was 46 and 45 mL, International Prostate Symptom Score (IPSS) was 7.04 and 7.08, and the health-related quality of life (HRQL) score was 1.57 and 1.56, in group-I and II, respectively. At 1 year the mean Q(max) was 23.4 and 25.9 mL/s, PVR was 32.5 and 24.1 mL, IPSS was 4.5 and 4.4, and the HRQL score was 1.2 and 1.1,) in group-I and II, respectively (P > 0.05). • Reoperation for recurrent obstruction was indicated in 4% in group-I and 5.2% in group-II (P > 0.05). • Secondary-HoLEP procedures seem to be safe and technically feasible with comparable functional outcomes as those of primary-HoLEP.

Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis

Objective To assess the effect of tranexamic acid on blood transfusion, thromboembolic events, and mortality in surgical patients.Design Systematic review and meta-analysis. Data sources Cochrane central register of controlled trials,...

Association Between Hospital Intraoperative Blood Transfusion Practices for Surgical Blood Loss and Hospital Surgical Mortality Rates

Blood loss during surgery is an important operative complication in patients undergoing major noncardiac surgery and may increase postoperative morbidity and mortality. Variations in the delivery of operative blood transfusions to treat blood loss depend not only on the patient and surgery characteristics but also on the hospital transfusion practices, and may explain differences in the hospitals' postoperative outcomes. We determine the relationship between hospital-level rates of intraoperative blood transfusion and 30-day mortality among older patients with significant intraoperative blood loss. Among 46,608 operative patients aged 65 years or older whose estimated blood loss was 500 mL or greater in 122 Veterans Affairs (VA) hospitals during years 1997 to 2004, we examined the relationship between hospital-level transfusion rates and adjusted 30-day postoperative mortality rates using linear regression modeling. Hospital-level rates of intraoperative blood transfusion for older surgical patients with significant blood loss varied from 10% to 92%. Hospitals in the highest tertile for the rate of intraoperative transfusion had the highest number of patients with 500 mL or more surgical blood loss and lowest risk-adjusted 30-day surgical mortality. For every 10% increase in the rate of intraoperative blood transfusion, there was a 0.7% (95% CI: 0.3%-1.1%) decrease in the hospital's adjusted 30-day postoperative mortality for these high-risk patients. Large variation exists in hospitals' intraoperative blood transfusion practices for older patients with significant surgical blood loss. Hospitals with higher transfusion rates for patients with significant surgical blood loss have lower adjusted 30-day mortality for these patients. Hospital intraoperative blood transfusion practices may be a promising surgical quality indicator.

Modified total cystectomy and neobladder: experience in 21 cases of invasive bladder cancer

Objective To summarize our experience in the modified total cystectomy and neobladder in patients with invasive bladder cancer.Methods Twenty one male patients with invasive bladder cancer were treated with modified total cystectomy and neobladder.Reconstruction of the lower urinary tract using modifiled ileal neobladder(in 17 patients)and sigmoid neobladder(in 4 patients)were performed.The median age of the patients was 62 years.The patients were followed up for 1-4 years.Clinical outcomes of these patients was evaluated,including the function of the neobladder,urinary function,renal function,serum electrolytes and QOL.Results There was no surgical mortality.The operating time was 3.5-6.5 h(mean,4.5 h).Blood transfusion was required in 4 cases.Fifteen patients(97 ％ had voluntary control of urination at daytime and 6 at night.They were functional to control urination 3-6 months after operation.Hydronephrosis to certain extent occurred in 5 patients,but was recovered after 6-8 months.There were one case of intestinal obstruction and one case of metabolic acidosis.Residual urinary volume was 30 ml in 1 cases and 40 ml in another.Conclusions Modified total cystectomy and neobladder is an ideal technique to treat invasive bladder cancer with good clinical outcomes of tumor control,high life quality,few severe complications and good urination control. Key words: Bladder tumor; Cystectomy; Intestinal neobladder; Urinary diversion

Anatomical versus nonanatomical resection of colorectal liver metastases: a meta-analysis

The purpose of the study was to compare anatomical resection (AR) versus nonanatomical resection (NAR) for colorectal liver metastases (CLM) with respect to perioperative and oncological outcomes. Literature search was performed to identify comparative studies reporting outcomes for both AR and NAR for CLM. Pooled odds ratios (OR) and weighted mean differences (WMD with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model. Seven nonrandomized controlled studies matched the selection criteria and reported on 1,662 subjects, of whom 989 underwent AR, and 673 underwent NAR for CLM. Compared with the perioperative results, NAR reduced the operation time (WMD, 0.39; 95% CI, 1.97-79.17) and blood transfusion requirement (OR, 2.98; 95% CI, 1.87-4.74), whereas postoperative morbidity and mortality were similar between the two groups. With respect to oncologic outcomes, there was no significant difference in surgical margins, overall survival and disease-free survival between the two groups. NAR is a safe procedure for CLM and does not compromise oncological outcomes. However, the findings have to be carefully interpreted due to the lower level of evidence.

Initiating a transfusion protocol for free diep flap breast reconstruction in North Bristol NHS Trust

Initiating a transfusion protocol for free diep flap breast reconstruction in North Bristol NHS Trust

The CORONIS Trial: international study of caesarean section surgical techniques

Design CORONIS is a pragmatic multicentre fractional factorial randomised controlled trial and is being conducted in sites in Argentina, Chile, Ghana, India, Kenya, Pakistan and Sudan [1]. Women are eligible if they are undergoing their first or second caesarean section through a transverse abdominal incision. Five comparisons will be carried out using a 2 balanced incomplete block factorial design. Each woman is allocated THREE of the five pairs of interventions using a bespoke secure webbased randomisation system (with 24/7 automated backup telephone system) hosted by the NPEU Clinical Trials Unit. The 5 pairs of interventions are: i. Blunt versus sharp abdominal entry ii. Exteriorisation of the uterus for repair versus intraabdominal repair iii. Single versus double layer closure of the uterus iv. Closure versus non-closure of the peritoneum (pelvic and parietal) v. Chromic catgut versus Polyglactin-910 for uterine repair Primary outcome: death or maternal infectious morbidity (one or more of the following: antibiotic use for maternal febrile morbidity during postnatal hospital stay, antibiotic use for endometritis, wound infection or peritonitis) or further operative procedures or blood transfusion. Sample size required: 15,000 women in total; minimum 9,000 women per comparison pair.

Living Donor Right Hepatectomy Using the Hanging Maneuver by Glisson’s Approach Under the Upper Midline Incision

The purpose of this study was to introduce an advanced technique for the best living donor right hepatectomy (LDRH) using the hanging maneuver by Glisson's approach under an upper midline incision. From January 2005 to February 2010, a total of 196 consecutive LDRHs have been performed at the National Cancer Center, Korea. To assess the overall outcomes of LDRH done with two significant technical developments--the upper midline incision and the initial Glisson's approach--we performed a comparative analysis involving all consecutive living donors, who we divided into three groups based on the two technical modifications over 5 years. Compared with the previous two groups, the third group of 32 consecutive living donors, from September 2009 to February 2010, demonstrated shorter operative time, shorter duration of hospital stay, and lower complication rate with no operative mortality, major morbidity, blood transfusion, or reoperation. All donors were fully recovered and returned to their previous activities. This LDRH using the hanging maneuver by Glisson's approach can be completed safely and effectively with good outcomes through an upper midline incision above the umbilicus, which may be a new milestone toward the best LDRH that donor surgeons can pursue.

Burn surgery and blood loss – a review

Objectives: Blood loss has long been recognised as a significant problem in burn surgery. Efforts have been made in the past to quantify this loss and determine what factors influence it the most. Several researchers have been able to produce and validate formulae that predict the volume of blood loss during excisional surgery. Accurately determining this allows appropriate volumes of blood to be ordered, reducing risk to patients and saving scarce resources. This article reviews the literature on blood loss in burns surgery, including influencing factors, methods of prediction and effective management. Methods: A literature review was conducted to examine methods used to measure, calculate and reduce blood loss in burn surgery. The validity of these methods and the limitations on accuracy will be discussed. Alternative methods shall also be considered. Results: Most current methods of estimating blood loss attempt to determine the volume of erythrocytes required to return haemoglobin concentrations to their pre-operative level. Various formulae have been developed to calculate this volume. Conclusions: Several authors have produced formulae that predict the volume of blood loss to a significant degree of accuracy. Different techniques have been shown to significantly reduce blood loss. In other areas of surgery, thromboelastometry has been used to identify the levels of specific blood component defects. The use of this method in burns surgery could, in the future, help develop a protocol for operative blood transfusion.

Precise hemihepatectomy guided by middle hepatic vein:a prospective study

Objective To investigate the efficacy of precise hemihepatectomy guided by middle hepatic vein(MHV),and to study the value of preoperative hepatic vein evaluation.Methods The clinical data of 68 patients who received hemihepatectomy at the Nanjing Drum Tower Hospital from October 2007 to September 2009were prospectively studied.Of the 68 patients,30 received precise hemihepatectomy guided by MHV(precise group)and 38 received anatomical hemihepatectomy(traditional group).The types of hepatic vein in the precise group were evaluated and classified preoperatively.The operation time,operative blood loss,volume of blood transfusion,liver function,morbidity and length of hospital stay of the 2 groups were compared.All data were analyzed using the t test,rank sum test,chi-square test and Fisher exact probability.Results According to the Nakamura's classification,there were 17(57%)patients with type Ⅰ,8(27%)with type Ⅱ and 5(16%)with type Ⅲ;according to the Kawasaki's classification,there were 11 patients with type Ⅰ(37%)and 19 with type Ⅱ(63%).There were 13 patients received right hepatectomy with MHV preservation,15 received left hepatectomy with MHV preservation,1 received right hepatectomy without MHV preservation and 1 received left hepatectomy without MHV preservation.There were no significant difference in the volume of operative blood loss and blood transfusion,level of alanine transaminase,total bilirubin,cholinesterase at postoperative day 3,total length of hospital stay and length of postoperative hospital stay between the 2 groups(t = 1.07,0.92,0.07,0.21,0.63,0.63,0.75,P ＞ 0.05).The operation time,levels of albumin at postoperative day 3 and complication rate were (342 ± 113)minutes,(35 ±3)g/L and 40%(12/30)in the precise group,and(270 ±73)minutes,(33 ±3)g/Land 66%(25/38)in the traditional group,respectively,with significant differences between the 2 groups(t =2.79,2.19;x2 =4.49,P＜0.05).The positive rates of the resection margin were 5%(1/19)in the precise group and 35%(8/23)in the traditional group,there was a significant difference between the 2 groups(P ＜0.05).ConclusionPreoperative hepatic vein evaluation and precise hemihepateetomy guided by MHV can preserve the functional liver tissues with venous drainage,achieve adequate tumor-free resection margin and reduce the postoperative complication rate. Key words: Precise hepatectomy; Hepatic vein classification; Middle hepatic vein; Preoperative evaluation

Preoperative Sclerotherapy of Facial Venous Malformations: Impact on Surgical Parameters and Long-Term Follow-Up

Purpose To analyze the operative benefit of preoperative sclerotherapy of facial venous malformations and assess long-term patient outcome. Materials and Methods Preoperative sclerotherapy was performed in 24 consecutive patients referred before resection of facial venous malformation. Pretreatment imaging was reviewed for malformation dimensions (length, width, and height), and volumes were estimated. Sclerotherapy was performed with 3% sodium tetradecyl in the first 15 patients and 98% dehydrated alcohol in the remaining 9 patients. Operative blood loss, operative time, transfusion requirement, and hospital stay were recorded. Operative time per lesion volume and operative blood loss per lesion volume were calculated. Results were compared with 15 historical control patients who underwent resection of facial venous malformations without preoperative sclerotherapy. Long-term follow-up of study and control patients was performed. Results Compared with controls, patients undergoing preoperative venous sclerotherapy were significantly older ( P = .0206) and had larger lesions in all three dimensions (height, P = .0002; length, P = .0010; width, P = .0004). Patients receiving sclerotherapy had shorter operative time per lesion volume ( P < .0001) and reduced blood loss per lesion volume ( P < .0001). Neither hospital stay nor the need for blood transfusion differed from the control patients ( P = .2449 and P = .6857). Mild periprocedural complications were encountered in 12.5% of cases, and nerve paresis occurred in 8.3% of cases. Long-term follow-up revealed retreatment was required in 2 of 24 patients (8.3%). Conclusions Preoperative sclerotherapy of venous malformations was associated with less operative time per lesion volume and less operative blood loss per lesion volume. Long-term follow-up revealed a low need for retreatment.

A retrospective statistical analysis of high-grade soft tissue sarcomas

Soft-tissue sarcomas have a mortality rate ranging from 40-60% for high-grade lesions. Prior identified risk factors for post-surgical mortality include tumor size, lesion histology, and margin status at resection. A better understanding of prognostic factors is needed to guide patient counseling and treatment. Data were collected from 129 patients surgically treated for high-grade extremity soft tissue sarcomas during 2002-2010. The primary endpoint was death related to high-grade soft tissue sarcoma. Thirteen variables were investigated: age, gender, race, tumor size, margin status, location, estimated blood loss, operative blood transfusions, pre-operative metastatic disease, pre-operative radiation, post-operative radiation, pre-operative chemotherapy, and post-operative chemotherapy. A Cox Survival Analysis model was created to determine the best predictors of survival time. Tumor size and the presence of pre-surgical metastasis were statistically significant predictors of overall survival. Patients with a tumor greater than 8 cm in any cross section had a 3.15 times greater chance of death. Presence of pre-surgical metastasis carried a 3.47 greater chance of death. The remaining variables did not predict patient outcomes in a statistically significant manner. The hazard ratios calculated add new data and can be used to more effectively guide patients in prognosis and treatment regimens.

Pediatric living donor liver transplantation: a report of 33 cases

Objective To evaluate the efficacy of living donor liver transplantation in the treatment of infants with end-stage liver diseases. Methods The clinical data of 33 infants who received living donor liver transplantation at the Renji Hospital of Shanghai Jiaotong University from October 2006 to September 2009 were retrospectively analyzed. The median age of the infants was 10.9 months, and the mean body weight was 8.2 kg.All of the grafts were left lateral lobes. Tacrolimus (or cyclosporine A) + steroid or tacrolimus (or cyclosporine A)+ steroid + mycophenolate mofeti] were applied to the infants to suppress the immune reaction. Operative techniques, perioperative management and results of follow-up were analyzed. Results The mean operation time,blood loss and blood transfusion of the donors were (384±108)minutes, (183±35) ml and O, and the three indexes of the recipients were (500± 103) minutes, (296±163) ml and (292 ± 159) ml , respectively. The cold preservation time of the grafts was (64 ±23)minutes, the mean weight of the grafts was (249 ±52)g, and the mean graft to recipient weight ratio was 2.1% ± 0.4%. All donors recovered smoothly and no complication occurred. Of the recipients, three were complicated with hepatic artery thrombosis, two with portal vein thrombosis,nine with biliary complications, 11 with infection, two with acute rejection and five infants died perioperatively.The one-year cumulative survival rate of the infants was 85% (28/33). Conclusions Infants with end-stage liver diseases could be treated by living donor liver transplantation. The development of surgical techniques and perioperative managements improves the success rate of operation and the long-term survival rate. Key words: End-stage liver diseases; Living donor liver transplantation; Infants

Advantage of autologous blood transfusion in surgery for hepatocellular carcinoma

To evaluate the significance of autologous blood transfusion (AT) in reducing homologous blood transfusion (HT) in surgery for hepatocellular carcinoma (HCC). The proportion of patients who received HT was compared between two groups determined by the time of AT introduction; period A (1991-1994, n = 93) and period B (1995-2000, n = 201). Multivariate logistic regression analysis was performed in order to identify independent significant predictors of the need for HT. We also investigated the impact of AT and HT on long-term postoperative outcome after curative surgery for HCC. The proportion of patients with HT was significantly lower in period B than period A (18.9% vs 60.2%, P < 0.0001). Multivariate logistic regression analysis identified AT administration as a significant independent predictor of the need for HT (P < 0.0001). Disease-free survival in patients with AT was comparable to that without any transfusion. Multivariate analysis identified HT administration as an independent significant factor for poorer disease-free survival (P = 0.0380). AT administration significantly decreased the need for HT. Considering the postoperative survival disadvantage of HT, AT administration could improve the long-term outcome of HCC patients.

Quantitative Assessment of the Advantages of Laparoscopic Gastrectomy and the Impact of Volume-Related Hospital Characteristics on Resource Use and Outcomes of Gastrectomy Patients in Japan

In this community-based study, we assessed the advantages of laparoscopic gastrectomy (LG) and the impact of volume-related hospital characteristics on gastrectomy care. The quality of gastrectomy care and the potential effects of volume-related hospital characteristics on gastrectomy care have not been comprehensively evaluated to date. We used a Japanese administrative database of 17,761 patients across 258 hospitals delivering both open gastrectomy and LG during 6-month periods in 2006, 2007, and 2008. We examined patient demographics, principal diagnosis, comorbidities, and complications, hospital patient volume, proportion of LG procedures accomplished, teaching status and care processes, length of hospital stay, total charge, and operative time. Multivariate analyses were used to compare LG with open gastrectomy in terms of mortality, complications, operative or postoperative blood transfusion, resource use and operative time. LG was performed in 3,914 (22%) patients and was associated with significantly shorter length of hospital stay, lower total charge, and longer operative time. Higher hospital volume was associated with less mortality, lower frequency of transfusion, shorter length of hospital stay, lower total charge, and shorter operative time. Higher procedures accomplished were associated with fewer complications, higher frequency of transfusion, greater resource use, and longer operative time. Laparoscopic gastrectomy offers significant economic advantages over open gastrectomy. However, LG was associated with increased operative time and required greater blood transfusion volume once indicated, which might drive gastrectomy care to use more prudent approaches in hospitals with higher procedures accomplished rates. Stakeholders should recognize the wide variation in hospital practices, skill training and efficient gastrectomy care, in addition to the volume-quality relationship.