Perioperative Laboratory Tests Research Articles

Evaluating the utility of perioperative laboratory tests in primary shoulder arthroplasty

BackgroundThe rising incidence of primary total shoulder arthroplasty (TSA) predicts a $4 billion increase in cost associated with this procedure by 2030. Studies have evaluated sources of cost containment, including inpatient services, namely routine perioperative laboratory tests. This study evaluates the utility of routine perioperative complete blood count (CBC) and basic metabolic panel (BMP) in TSA and identifies predictors of abnormal postoperative laboratory results and the need for medical intervention (NMI). MethodsAll patients undergoing primary TSA from 2013 to 2020 at a single institution were included. Demographics, comorbidities, procedural details, and preoperative and postoperative CBC and BMP values were recorded. Abnormal values were identified for each laboratory parameter. NMI was defined as postoperative blood transfusion, electrolyte repletion, fluid resuscitation, and inpatient medical consultation. Univariate and multivariate analyses were performed to determine independent predictors for abnormal postoperative CBC and BMP (AbBMP) results and NMI. A P value < .05 was considered statistically significant. ResultsA total of 328 patients were included in the study, with 202 (61.6%) female patients and a median age of 70.5 years. Medical intervention was required in 115 (35.1%). There were no differences in rates of NMI based on patient demographics, comorbidities, and preoperative CBC and BMP results, although there was a significant difference in rates of NMI when comparing postoperative serum potassium (4.1 mmol/L in no NMI group; 3.9 mmol/L in NMI group; P = .039). Ultimately, there were no demographic, surgical, or laboratory factors associated with postoperative NMI on predictive modeling. Increasing body mass index (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.15, P < .03), preoperative serum glucose (OR 1.05, 95% CI 1.02-1.08, P = .003), and preoperative serum blood urea nitrogen (OR 1.12, 95% CI 1.05-1.12, P = .01) are associated with an 8.0%, 5.0%, and 12% increase in odds of an AbBMP, respectively. Preoperative potassium is inversely correlated with odds of AbBMP (OR 0.19, 95% CI 0.05-0.67, P = .01). ConclusionsAlthough postoperative laboratory tests were routinely obtained following primary shoulder arthroplasty, abnormal postoperative CBC and BMP were not associated with NMI. Postoperative BMP tests should be considered in patients with elevated body mass index, elevated preoperative serum glucose, elevated preoperative serum blood urea nitrogen, and those with preoperative serum hypokalemia. Postoperative CBC tests are likely not necessary after primary shoulder arthroplasty.

Predictive Accuracy of a Perioperative Laboratory Test–Based Prediction Model for Moderate to Severe Acute Kidney Injury After Cardiac Surgery

Effective treatment of acute kidney injury (AKI) is predicated on timely diagnosis; however, the lag in the increase in serum creatinine levels after kidney injury may delay therapy initiation. To determine the derivation and validation of predictive models for AKI after cardiac surgery. Multivariable prediction models were derived based on a retrospective observational cohort of adult patients undergoing cardiac surgery between January 2000 and December 2019 from a US academic medical center (n = 58 526) and subsequently validated on an external cohort from 3 US community hospitals (n = 4734). The date of final follow-up was January 15, 2020. Perioperative change in serum creatinine and postoperative blood urea nitrogen, serum sodium, potassium, bicarbonate, and albumin from the first metabolic panel after cardiac surgery. Area under the receiver-operating characteristic curve (AUC) and calibration measures for moderate to severe AKI, per Kidney Disease: Improving Global Outcomes (KDIGO), and AKI requiring dialysis prediction models within 72 hours and 14 days following surgery. In a derivation cohort of 58 526 patients (median [IQR] age, 66 [56-74] years; 39 173 [67%] men; 51 503 [91%] White participants), the rates of moderate to severe AKI and AKIrequiring dialysis were 2674 (4.6%) and 868 (1.48%) within 72 hours and 3156 (5.4%) and 1018 (1.74%) within 14 days after surgery. The median (IQR) interval to first metabolic panel from conclusion of the surgical procedure was 10 (7-12) hours. In the derivation cohort, the metabolic panel-based models had excellent predictive discrimination for moderate to severe AKI within 72 hours (AUC, 0.876 [95% CI, 0.869-0.883]) and 14 days (AUC, 0.854 [95% CI, 0.850-0.861]) after the surgical procedure and for AKI requiring dialysis within 72 hours (AUC, 0.916 [95% CI, 0.907-0.926]) and 14 days (AUC, 0.900 [95% CI, 0.889-0.909]) after the surgical procedure. In the validation cohort of 4734 patients (median [IQR] age, 67 (60-74) years; 3361 [71%] men; 3977 [87%] White participants), the models for moderate to severe AKI after the surgical procedure showed AUCs of 0.860 (95% CI, 0.838-0.882) within 72 hours and 0.842 (95% CI, 0.820-0.865) within 14 days and the models for AKI requiring dialysis and 14 days had an AUC of 0.879 (95% CI, 0.840-0.918) within 72 hours and 0.873 (95% CI, 0.836-0.910) within 14 days after the surgical procedure. Calibration assessed by Spiegelhalter z test showed P >.05 indicating adequate calibration for both validation and derivation models. Among patients undergoing cardiac surgery, a prediction model based on perioperative basic metabolic panel laboratory values demonstrated good predictive accuracy for moderate to severe acute kidney injury within 72 hours and 14 days after the surgical procedure. Further research is needed to determine whether use of the risk prediction tool improves clinical outcomes.

Postoperative seizures following endoscopic third ventriculostomy and choroid plexus cauterization: a case series.

In this study, the authors sought to investigate variables associated with postoperative seizures following endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) for treatment of pediatric hydrocephalus. A retrospective analysis of 37 patients who underwent ETV/CPC for treatment of hydrocephalus at an academic medical center from September 2016 to March 2021 was conducted. Demographics, etiology of hydrocephalus, operative details, electroencephalography (EEG) data, MRI findings, need for subsequent procedures, perioperative laboratory tests, medical history, and presence of clinical postoperative seizures were collected. Postoperative seizures were defined as clinical seizures within 24 hours of surgery. Eighteen patients received levetiracetam intraoperatively as well as over the next 7 days postoperatively for seizure prophylaxis. Of 37 included patients, 9 (24%) developed clinical seizures within 24 hours after surgery, 5 of whom subsequently had electroclinical seizures captured on video-EEG. The clinical seizures in 4 of those 5 patients (80%) may have been associated with the hemisphere of the brain through which the endoscope was introduced. The median corrected age of the cohort was 3.4 months. The median corrected age of patients who did not develop postoperative seizures was 2.3 months compared with 0.7 months for patients who did develop postoperative seizures (p > 0.99). Postoperative seizures occurred in 43% (3/7) of prenatally repaired myelomeningocele patients versus 29% (2/7) of postnatally repaired myelomeningocele patients. Of the 18 patients who received prophylactic levetiracetam, none (0%) developed postoperative seizures compared with 9 of the 19 patients (47%) who did not receive prophylactic levetiracetam (p = 0.014). Postoperative seizures were recorded in 24% of the pediatric patients who underwent ETV/CPC for hydrocephalus, which is higher than previously reported rates in the literature of 5%. Since 80% of the postoperative electrographic seizures may have been associated with the hemisphere through which the endoscope was introduced, the surgical entry site may contribute to postoperative seizure development. In patients who received prophylactic perioperative levetiracetam, the postoperative seizure incidence dropped to 0% compared with 47% in those who did not receive prophylactic perioperative levetiracetam. This finding indicates that the use of prophylactic perioperative levetiracetam may be efficacious in the prevention of clinical seizures in this patient population.

Usefulness of Perioperative Laboratory Tests in Total Hip and Knee Arthroplasty: Are They Necessary for All Patients?

BackgroundLaboratory studies are routinely obtained preoperatively and postoperatively for total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study evaluates the necessity of routine, perioperative laboratory tests and identifies risk factors for laboratory-associated interventions.MethodsThis retrospective review evaluated 967 consecutive patients scheduled for primary, unilateral TKAs (n = 593) or THAs (n = 374) over an 18-month period at a single institution. Preoperative prothrombin time (PT) and International Normalized Ratio (INR), complete blood count (CBC), complete metabolic panel (CMP), and postoperative CBC and basic metabolic panel (BMP) were recorded along with any laboratory-associated intervention. Patient demographics and comorbidities identified risk factors for abnormal or actionable laboratory studies.ResultsPreoperatively, the actionable rates for PT/INR, CMP, and CBC were 0.3%, 1.4%, and 0.5%, respectively. Vascular, renal, and immunologic diseases were risk factors for an actionable CBC. Risk factors for an actionable CMP include cardiac arrhythmia and diabetes. There were no risk factors for an actionable PT/INR. Postoperatively, only 1.5% of BMPs and 1.5% of CBCs were actionable. Congestive heart failure, renal disease vascular disease, or history of cancer (P = .030) were risk factors for an actionable CBC. There were no risk factors for an actionable BMP. Patients with an abnormal preoperative lab were 2.4 times more likely to have an actionable postoperative lab. Patients with an actionable preoperative lab were 11.3 times more likely to have an actionable postoperative lab.ConclusionRoutine preoperative and postoperative labs may not be necessary on all patients undergoing a TKA or THA. Comorbid risk factors and abnormal or actionable preoperative CMPs and CBCs can help determine the usefulness of postoperative laboratory assessments.

Analysis of the risk factors of acute kidney injury after total hip or knee replacement surgery.

Background Postoperative acute kidney injury (AKI), which increases the risk of postoperative morbidity and mortality, poses a major concern to surgeons. We conducted this study to analyze the risk factors associated with the occurrence of AKI after orthopedic surgery.Methods This was a retrospective study that included 351 patients who underwent total hip or knee replacement surgery at Inje University Haeundae Paik Hospital between January 2012 and December 2016.Results AKI occurred in 13 (3.7%) of the 351 patients. The patients’ preoperative estimated glomerular filtration rate (eGFR) was 66.66±34.02 mL/min/1.73 m2 in the AKI group and 78.07±21.23 mL/min/1.73 m2 in the non-AKI group. The hemoglobin levels were 11.21±1.65 g/dL in the AKI group and 12.39±1.52 g/dL in the non-AKI group. Hemoglobin level was related to increased risk of AKI (odds ratio [OR], 0.13; 95% confidence interval [CI], 0.02–0.68; p=0.016). Administration of crystalloid or colloid fluid alone and the perioperative amount of fluid did not show any significant relationship with AKI. Further analysis of the changes in eGFR was performed using a cutoff value of 7.54. The changes in eGFR were significantly related to decreased risk of AKI (OR, 0.74; 95% CI, 0.61–0.89; p=0.002).Conclusion Renal function should be monitored closely after orthopedic surgery if patients have chronic kidney disease and low hemoglobin level. Predicting the likelihood of AKI occurrence, early treatment of high-risk patients, and monitoring perioperative laboratory test results, including eGFR, will help improve patient prognosis.

Utility of Perioperative Laboratory Tests in Pediatric Patients Undergoing Spinal Fusion for Scoliosis

Study DesignRetrospective comparative study. ObjectivesWe aimed to characterize the frequency of perioperative laboratory tests for posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and to assess whether test results affected clinical management. Summary of Background DataPerioperative laboratory tests for PSF including complete blood count, coagulation laboratory tests, basic metabolic panels (BMPs), and type and screen, are commonly ordered based on providers' discretion or existing order sets. Studies have shown unnecessary laboratory tests as financially and physically costly in adults; however, no studies have examined the necessity of common perioperative laboratory tests in pediatric spinal deformity surgery. MethodsRetrospective review of patients aged 10–18 years who underwent PSF for AIS at our center in the past three years. The clinical utility of perioperative laboratory tests was assessed based on detected incidence of anemia, blood transfusions, hematology/endocrinology/nephrology consultations, insulin administration, and postponed/canceled surgeries. ResultsA total of 234 patients were included (mean age 14.4 ± 1.8 years, 75% female). Of 105 (44.9%) patients with preoperative coagulation laboratory tests, 21 (20%) had abnormal results; however, none had subsequent hematology consultations or canceled/postponed surgeries. Postoperatively, only 5 (2.1%) patients and 30 (12.8%) patients had hemoglobin values less than 8 g/dL on postoperative day (POD) 1 and 2, respectively. Multivariate analysis identified POD1 hemoglobin ≤9.35 g/dL as the only predictor of hemoglobin <8 g/dL on POD2. Overall, there were 8 (3.4%) indicated blood transfusions postoperatively. Costs of unnecessary laboratory tests averaged $95.27 (range $49.72 to $240.27) per patient. ConclusionsMany perioperative laboratory orders may be unnecessary in pediatric spinal deformity surgery, subjecting patients to extraneous costs and needlesticks. In particular, preoperative coagulation laboratory tests, perioperative BMPs, and additional postoperative CBCs for those with hemoglobin >9.35 on POD1 may not be warranted. Level of EvidenceLevel III, retrospective cohort study.

Assessing the Need for Common Perioperative Laboratory Tests in Pediatric Patients With Femoral Shaft Fractures.

Femoral shaft fractures are a common cause for hospital admission and surgery in pediatric patients, and laboratory studies are often ordered for historical concerns of excessive bleeding. Recent literature has challenged these assumptions, and unnecessary testing causes undue pain and costs in children. No previous studies have offered evidence-based recommendations for perioperative laboratories in isolated pediatric femoral shaft fractures. We retrospectively reviewed all patients presenting with femoral shaft fractures at our pediatric trauma center between 2013 and 2017. Patients with multitrauma injuries, metabolic/neuromuscular diseases, or intensive care unit stays were excluded. Necessity of laboratory tests was determined by rates of anemia, blood transfusions, specialist consultations, and delayed surgeries. Ordering patterns were recorded, with cost estimation based on Healthcare Bluebook. We reviewed 95 patients (mean age, 7.9±4.8 y; 70 males). Treatments included elastic nails (33/95, 34.7%), reamed intramedullary nails (24/95, 25.3%), plates/screws (12/95, 12.6%), and spica casting (26/95, 27.4%). Of 32 patients with preoperative coagulation laboratories, 11 were abnormal; however none resulted in hematology consultations or procedure delays. Seventy-five patients (78.9%) and 15 patients (15.8%) had complete blood counts preoperatively and postoperative day 1, respectively. Four patients (4.2%) had hemoglobin<8 g/dL postoperatively, however, there were no perioperative blood transfusions. Of these 4, 3 underwent either reamed intramedullary nails or open reduction internal fixation with plates/screws. Twenty-six patients (27.4%) had preoperative basic metabolic panels that did not alter medical care. On the basis of our criteria, over 72% of laboratories appeared unnecessary, with a total potential cost of $8567. Over 80% of orders were from the emergency department by residents or attending physicians. Perioperative laboratory orders may be unnecessary in most isolated pediatric femoral shaft fractures, subjecting patients to extraneous costs, and associated pain. However, laboratories may be justified based on clinical circumstances or for older patients treated with reamed nails or plates/screws. Evidence-based recommendations for perioperative laboratory orders offer the potential to improve quality and value and minimize harm in pediatric orthopaedic trauma. Level III-retrospective comparative study (therapeutic).

Comparison of the Extent Classification and the New Complexity Classification of Hepatectomy for Prediction of Surgical Outcomes: a Retrospective Cohort Study

BackgroundIn predicting the risk for posthepatectomy complications, hepatectomy is traditionally classified into minor or major resection based on the number of resected segments. Recently, a new hepatectomy complexity classification was proposed. This study aimed to compare the value of the traditional and that of the new classification in perioperative outcomes prediction. MethodsDemographics, perioperative laboratory tests, intraoperative and postoperative outcomes, and follow-up data of patients with hepatocellular carcinoma who underwent liver resection were retrospectively analyzed. ResultsA total of 302 patients were included in our study. Multivariable analysis of intraoperative variables showed that the complexity classification could independently predict the occurrence of blood loss > 800 mL, operation time > 4 h, intraoperative transfusion, and the use of Pringle’s maneuver (all p < 0.05). For postoperative outcomes, the high-complexity group was independently associated with severe complications, and hepatic-related complications (all p < 0.05); the traditional classification was independently associated only with posthepatectomy liver failure (PHLF) (p = 0.004). ConclusionsComplexity classification could be used to assess the difficulty of surgery and was independently associated with postoperative complications. The traditional classification did not reflect operation complexity and was associated only with PHLF.

Inhaled nitric oxide therapy was not associated with postoperative acute kidney injury in patients undergoing lung transplantation: A retrospective pilot study.

Inhaled nitric oxide (iNO) therapy is commonly used in lung transplantation (LT) recipients during the perioperative periods. However, previous studies report that the use of iNO may increase the risk of renal dysfunction. Post-LT acute kidney injury (AKI) can lead to critical situations, including prolonged intensive care unit or hospital stays and increased morbidity and mortality. Accordingly, the aim of this study was to investigate the relationship between iNO therapy and incidence of post-LT AKI in LT recipients.The medical data of 36 patients who underwent LT surgery from January 2012 to July 2017 in a single university hospital setting were retrospectively collected and analyzed. Patients were divided into 2 groups: iNO (n = 14) and control (n = 19). The demographic data, anesthetic methods, complications, and perioperative laboratory test values of each patient were assessed. Patients were categorized according to changes in plasma creatinine (Cr) concentration levels within 48 hours after LT using Acute Kidney Injury Network criteria.There was no significant difference in the occurrence (P = .13) and severity (P = .9) of post-LT AKI between iNO and control groups. The mean serum Cr levels after surgery were 0.91 ± 0.44 and 0.81 ± 0.37 mg/dL in the iNO and control groups, respectively (P = .50).AKI plays a critical role in the prognosis of LT recipients. Our results revealed that iNO therapy was not associated with the incidence of post-LT AKI. Therefore, if iNO treatment is indicated, active use under close monitoring of renal function is recommended in LT-patients concerned about AKI after surgery.

Changes of plasma fibrinogen level in postoperative bleeding patients undergoing cardiac surgery with cardiopulmonary bypass

Objective To evaluate perioperative fibrinogen levels as a predictor of postoperative bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Methods In this single-center, observational cohort study of 623 patients following cardiac surgery with CPB, excessive bleeding group was defined as patients with a 24 h chest tube output (CTO) exceeding the 90th percentile of distribution. According to the occurrence of excessive bleeding, the patients were divided into 2 groups: excessive bleeding group and control group. A total of 63 patients were identified as having excessive bleeding (10.1%), and the rest were classed as control group. The possible risk factors associated with excessive bleeding were retrospectively analyzed. Hemoglobin, platelet count, prothrombin time, activated partial thrombolastin time, and fibrinogen level were measured before the surgery (T0), and at admission to the intensive care (T1). Results At T1, there was significant difference in fibrinogen levels (t=3.763, P=0.001) between the two groups. The fibrinogen level at T1 was significantly correlated with the 24 h CTO (r=-0.114, P=0.000). Multivariate analysis demonstrated that the fibrinogen level [P=0.001, odds ratio (OR)=0.590, 95% confidence interval (CI): 0.463-0.771] at T1 was the best perioperative standard laboratory test to predict excessive bleeding, whereas preoperative fibrinogen level was not a predictor. Body mass index (P=0.045, OR=0.814, 95%CI: 0.991-1.010), asprin treatment (P=0.012, OR=1.248, 95%CI: 1.050-1.484), previous cardiac surgery (P=0.027, OR=2.771, 95%CI: 1.469-3.142), CPB time (P=0.002, OR=1.614, 95%CI: 1.196-2.179), the hemoglobin level (P=0.014, OR=0.857, 95%CI: 0.758-0.969), the prothrombin time (P=0.005, OR=1.212, 95%CI: 1.124-1.323) at T1 were the other common predictors. The receiver operating characteristics curve analyses revealed at T1 the best fibrinogen level cutoff to predict postoperative bleeding was 2.2 g/L. Conclusion In this study, the fibrinogen level upon admission to the intensive care unit after CPB predicted the risk of postoperative bleeding. Our data add to the concern regarding the fibrinogen level threshold that might require fibrinogen concentration infusion to reduce postoperative blood loss. Key words: Fibrinogen; Postoperative blood loss; Cardiopulmonary bypass

The Association of Preoperative Body Mass Index with Acute Kidney Injury in Liver Transplantation Recipients: A Retrospective Study.

BackgroundLiver transplantation (LT) is a complicated procedure with a high incidence of postoperative acute kidney injury (AKI). Previous studies indicate that even transient or mild post-LT AKI can result in critical conditions, including prolonged stays in hospitals and intensive care units and increased morbidity and mortality. The aim of this study was to investigate the association between body mass index (BMI) and occurrence of AKI in LT recipients.MethodsMedical data from 203 patients who received LT surgery from January 2010 to August 2016 in a single university hospital setting were retrospectively collected and analyzed. Patients were classified as either underweight (BMI <20 kg/m2) or normal weight (20 ≤ BMI < 30 kg/m2). Demographic data, anesthetic methods, complications, and perioperative laboratory test values of each patient were assessed. Propensity analyses and logistic regression were performed to evaluate the association between BMI and post-LT AKI.ResultsThere was no significant difference in occurrence of post-LT AKI between underweight and normal weight patients. The underweight patient group had significantly longer hospital stay compared with the normal weight patient group (P = 0.023).ConclusionsBMI classification was neither a positive nor negative predictor of postoperative AKI occurrence. However, patients with lower BMI had significantly longer hospital stay compared with their counterparts. Although our study was limited by its retrospective design, our observations suggest that lower BMI might play a role in post-LT AKI.

Influence of two types of intraoperative colloids infusion on the renal function of adolescent patients with scoliosis: a retrospective study

Objective To compare the renal function between 6% hydroxyethyl starch(130/0.4) and 4% succinylated gelatin during posterior spinal orthopaedic surgery for adolescent patients with scoliosis. Methods One thousand and nineteen adolescent patients with scoliosis who had underwent posterior spinal orthopaedic surgery in Nanjing Drum Tower Hospital from November 2011 to October 2015 were retrospectively reviewed. According to the types of colloids, patients were divided into two groups: hydroxyethyl starch(group H, n=849) and succinylated gelatin(group G, n=170). Patients′ demographic and perioperative information including sex, age, ASA grade, BMI, duration of operation, the volume of intraoperative fluid therapy, blood loss, postoperative drainage, the length of hospital stay after surgery, perioperative blood transfusion and laboratory tests were collected and compared between the two groups. Results The incidence of acute kidney injury(AKI) in group H was higher than group G: 0.08% vs 0, but the difference was not statistically significant(P>0.05). With regards to length of hospital stay after surgery, blood transfusion or postoperative drainage, there were no significant differences between the two groups(P>0.05). Conclusions There were no significant differences in incidence of AKI between hydroxyethyl starch and succinylated gelatin during posterior spinal orthopaedic surgery for adolescent patients with scoliosis. Key words: Hydroxyethyl starch; Succinylated gelatin; Scoliosis; Acute kidney injury

Perioperative Laboratory Abnormalities in Gynecologic Oncology Surgical Patients.

Background: Laboratory blood testing incurs financial costs and the blood draws can increase discomfort, yet minimal data exists regarding routine testing in gynecologic oncology surgical patients. Additionally, an increasing number of gynecologic oncology surgeries are performed via a laparoscopic approach. Thus, further investigation into perioperative laboratory testing for gynecologic oncology patients is warranted. An increasing number of gynecologic oncology surgeries are performed via a laparoscopic approach. Thus, further investigation into perioperative laboratory testing for gynecologic oncology patients is warranted. Objective: The aims of this study were (1) to evaluate the frequency and etiology of perioperative laboratory test abnormalities in patients undergoing laparoscopic and laparotomy surgery in a gynecologic oncology service, and (2) to establish an evidence-based algorithm to reduce unnecessary laboratory testing. Materials and Methods: A single-institution retrospective study was completed, investigating laparoscopic and laparotomic surgeries over 4 years. Information on preoperative and postoperative laboratory data, surgical parameters, perioperative interventions, and patient demographics was collected. Quality-assurance data were reviewed. Data were tabulated and analyzed using Statistical Product and Service Solutions (SPSS) version 22. A Student's t-test was used to test for group differences for continuous variables with equal variance, the Mann-Whitney–U test for continuous variables when unequal variance was detected, and Pearson's χ2 was used to investigate categorical variables of interest. p-Values <0.05 were considered to be statistically significant. Logistic regression was performed to investigate the relationships among multiple predictors and each identified outcome. Results: The study included 481 subjects (168 laparoscopies, 313 laparotomies). Patients undergoing laparoscopy were, on average, younger (53.5 versus 57.4), with lower body mass indexes (29.7 versus 33.0) and lower rates of diabetes (10.7% versus 19.5%), compared to patients undergoing laparotomy. Overall, >98% of patients underwent at least one preoperative and postoperative laboratory test, totaling 8060 preoperative and 5784 postoperative results. The laparoscopy group was significantly less likely to have postoperative metabolic abnormalities or to undergo perioperative blood transfusion. Patients taking an angiotensin-converting-enzyme inhibitor, angiotensin-II–receptor blocker, or diuretic were significantly more likely to have elevated creatinine preoperatively (odds ratio [OR]: 5.0; p < 0.001) and postoperatively (OR: 7.1; p < 0.001), and this remained true for each group when divided by surgical approach. Perioperative complications meeting institutional quality assurance criteria occurred in 1.7% of laparoscopy patients compared to 11.8% of laparotomy patients (p < 0.001); perioperative laboratory testing was not a factor in the diagnosis of these complications. Conclusions: Clinically significant laboratory abnormalities are uncommon and are less likely to be found on routine perioperative testing in gynecologic oncology patients undergoing laparoscopy, compared to patients undergoing laparotomy. This suggests a role for limiting perioperative laboratory blood testing. (J GYNECOL SURG 32:111)

Role of total hip replacement arthroplasty between transplantation and acute kidney injury

Osteonecrosis of the femoral head is a severely disabling complication of steroid immunosuppression in renal transplant patients. The increased number of patients undergoing transplantation has increased the number of transplant recipients undergoing total hip replacement arthroplasty (THRA). In this study, we retrospectively assessed patients who underwent THRA from May 2004 to February 2014, and evaluated their demographic and clinical characteristics, the results of peri-operative laboratory tests, the amounts of fluids transfused during surgery, and anesthesia time. Our results found that post-operative acute kidney injury (AKI) was significantly associated with transplantation, and transplantation was an independent factor predictive of post-operative AKI, so transplant recipients are at risk for AKI following THRA. Total hip replacement is a safe and effective treatment for transplant recipients and, in view of their limited life expectancy, should be considered at an early stage in their treatment.

Transplantation Is a Risk Factor for Acute Kidney Injury in Patients Undergoing Total Hip Replacement Arthroplasty for Avascular Necrosis: An Observational Study

BackgroundThe increased number of patients undergoing transplantation has increased the number of transplant recipients undergoing total hip replacement arthroplasty (THRA). We have evaluated the association between transplantation and acute kidney injury (AKI) in patients undergoing THRA. MethodsPatients who underwent THRA from May 2004 to February 2012 were retrospectively assessed. Their demographic and clinical characteristics, the results of perioperative laboratory tests, the amounts of fluids transfused during surgery, and anesthesia time were evaluated. Patients were divided into 2 groups: transplant (n = 222) and nontransplant (n = 2,044) patients. With use of the maximal Acute Kidney Injury Network criteria, AKI was evaluated by changes in creatinine concentration within 48 hours of THRA. Propensity analyses and logistic regression were performed to evaluate the association between transplantation and postoperative AKI. ResultsPostoperative AKI was significantly associated with transplantation (P < .0001), and transplantation was an independent factor predictive of postoperative AKI (P < .0001). ConclusionsTransplant recipients are at risk for AKI following THRA. The mechanism by which organ transplantation enhances postoperative AKI warrants further evaluation.

Single‐Incision Versus Conventional Laparoscopic Cyst Excision and Roux‐Y Hepaticojejunostomy for Children With Choledochal Cysts: a Case‐Control Study

The aim of this study was to compare the efficacy of single-incision laparoscopic hepaticojejunostomy (SILH) with that of conventional laparoscopic hepaticojejunostomy (CLH) for children with choledochal cysts (CDCs). Patients undergoing SILH between April 2011 and April 2012 were matched with those undergoing CLH between January 2009 and April 2011 for age, sex, CDC types, size, and operative surgeon. The operating time, postoperative hospital stay, time to full feed, postoperative complications, and perioperative laboratory tests were compared. A total of 150 patients (SILH 75, CLH 75) were evaluated. Median follow-up periods of SILH and CLH groups were 12 and 34 months, respectively. The postoperative hospital stay and time required for resumption of full diet were similar for the two groups (p = 0.93 and 0.16, respectively). Early in the series, one (1.3 %) SILH patient developed bile leak. It was successfully managed with 10 days of drainage. No mortality or morbidities-anastomotic stenosis, cholangitis, pancreatic leak, intestinal obstruction, intrahepatic reflux-were encountered. Overall complication rates were identical in the two groups (p = 0.32). SILH is safe in the hands of experienced laparoscopic hepaticobiliary surgeons. It achieves comparable outcomes with less surgical scar.

Initial Experience of Single-Incision Laparoscopic Hepaticojejunostomy Using Conventional Instruments for Correctable Biliary Atresia

Single-incision laparoscopic surgery aims to minimize surgical trauma. Yet there has been no report on its application to the treatment of correctable biliary atresia (BA). We present here our initial mini-series of successful single-incision laparoscopic hepaticojejunostomy (SILH) for correctable BA. We reviewed 4 correctable BA patients (Type I/II, 3/1) who underwent SILH between May and July 2011. Ultrasonography, upper gastrointestinal contrast studies, and blood tests were performed during the follow-up period. The age at operation, operative time, postoperative hospital stay, resumption of full diet, postoperative complications, and perioperative laboratory tests were evaluated. The median age at operation was 21 days. The median operative time was 2 hours. Blood loss was minimal. The median follow-up duration was 4.5 months. Jaundice gradually declined after 3-5 days in Type I and 6 days in Type II BA patient. There was no mortality or surgical complication so far. In experienced hands, SILH for treatment of correctable BA is safe and effective.

Laparoscopic versus Open Roux-en-Y hepatojejunostomy for children with choledochal cysts: intermediate-term follow-up results

Laparoscopic hepatojejunostomy (LH) for children with choledochal cysts (CDC) has been gaining popularity recently. However, its safety and efficacy remain unknown. The purpose of this study was to evaluate the intermediate-term results of LH for CDC children. We reviewed 218 patients who underwent LH between October 2001 and October 2009 and 200 patients who underwent open hepatojejunostomy (OH) between September 1993 and September 2001. Ultrasonography, upper gastrointestinal contrast studies, and laboratory tests were performed during the follow-up period. Age, operative blood loss, operative time, postoperative hospital stay, time to full feed, duration of drainage, postoperative complications, and perioperative laboratory tests were evaluated in both groups. The median follow-up periods of the LH and OH groups were 38 and 146 months, respectively. There was no significant difference in age between the two groups. Interestingly, the operative time of the LH group decreased significantly with increasing number of cases (P<0.01). The most recent operative time of the LH group did not differ from that of the OH group (3.04 vs. 2.95 h, P=0.557). The operative blood loss of the LH group was significantly less (P<0.001). The postoperative hospital stay, resumption of alimentation, and duration of drainage in the LH group were significantly shorter (P<0.001, respectively). Two of 218 (0.9%) LH patients developed bile leak. This was significantly less than 11 of 200 (5.5%) in the OH group (P<0.01). The morbidities of LH group were significantly lower than those of the OH group. Postoperative liver function tests and serum amylase levels normalized in both groups (P<0.001). Laparoscopic hepatojejunostomy is safe and effective. Its intermediate-term results are comparable to open surgery.

Biochemical Markers Predict Morbidity and Mortality after Pancreaticoduodenectomy

The association between routinely ordered perioperative laboratory tests and postoperative morbidity and mortality after pancreaticoduodenectomy has not been well characterized. Routine perioperative laboratory data were analyzed for 2,894 patients who underwent a pancreaticoduodenectomy over a 25-year period. Laboratory values were initially categorized as being above or below the 75th percentile for the study population, and biochemical markers of morbidity and mortality were identified using multivariate logistic regression. The most significant biochemical markers were studied in greater detail by regrouping patients into low, intermediate, and high categories. Significant multivariate predictors of a postoperative complication included preoperative blood urea nitrogen> or =18 mg/dL, preoperative albumin< or =3.5 g/dL, and postoperative amylase> or =292 U/L. Significant multivariate predictors of a postoperative death included preoperative albumin< or =3.5 g/dL and postoperative aminotransferase> or =187 U/L. Postoperative hyperamylasemia was found to be associated, in particular, with an increased pancreatic fistula rate. Pancreatic fistula rates in the low (0 to 99 U/L), intermediate (100 to 399 U/L), and high (> or = 400 U/L) postoperative amylase groups were 4%, 14%, and 20%, respectively. Postoperative mortality rates in patients with low (0 to 499 U/L), intermediate (500 to 1,999 U/L), and high (> or = 2,000 U/L) postoperative aminotransferase groups were 0.9%, 5%, and 29%, respectively. Postoperative mortality rates in the high (> 3.5 g/dL), intermediate (2.6 to 3.5 g/dL), and low (0 to 2.5 g/dL) albumin groups were 0.9%, 3%, and 7%, respectively. Routine perioperative laboratory tests can help surgeons identify patients who are at increased risk for morbidity and mortality after pancreaticoduodenectomy.