Preoperative Transfusion Research Articles

Blood management in total hip arthroplasty: a nationwide trend analysis from 2011 to 2018.

With the advent of practice changes surrounding preoperative patient optimization and postoperative protocols, a marked reduction has been reported in blood transfusion rates following total hip arthroplasty (THA). Thus, the purpose of this study was to examine differences in the prevalence of preoperative anemia, thrombocytopenia, elevated international normalized ratio (INR), bleeding disorders, and pre- and postoperative blood transfusions over the last decade. From 2011 to 2018, the American College of Surgeons National Quality Improvement Program database was queried for all primary THA procedures (n = 208,796). The following continuous variables were examined using analysis of variance: preoperative hematocrit (HCT), platelet count, and INR. The following categorical variables were analyzed by chi-squared tests: anemia (HCT < 35.5% for females and < 38.5% for males), thrombocytopenia (platelet count < 150,000/µL), INR > 2.0, bleeding disorders, preoperative transfusions, and postoperative transfusions. There were decreases in preoperative anemia (2011: 16.2%; 2018: 11.4%, p < 0.001) and postoperative transfusions (2011: high = 22.2%; 2018: low = 1.3%, p < 0.001). Statistically significant but clinically irrelevant changes were observed in preoperative HCT (2011: low = 40.3, 2018: high = 41.1, p < 0.001), platelet count (2011: low = 248,700; 2018: high = 250,100, p < 0.001), thrombocytopenia (2011: high = 4.9%; 2018: low = 4.3%, p = 0.036), INR > 2.0 (2011: high = 1.1%; 2018: low = 0.7%, p = 0.001), bleeding disorders (2011: high = 2.9%; 2018: low = 2.0%, p < 0.001), and preoperative transfusions (2011: high = 0.2%; 2018: low = 0.1%, p = 0.007). Large decreases in the number of patients with preoperative anemia and those receiving postoperative blood transfusion were observed during the study period. Future investigation is needed to ascertain whether this is due to patient optimization, practice changes, "cherry-picking" of healthy patients, or a combination of these factors. III.

Collateral damage of COVID-19 pandemic: The impact on a gynecologic surgery department

ObjectiveThis study focuses on changes in gynecologic surgical activity at Hospital Foch, Paris, France during the first French COVID lockdown in 2020. Additional goals include the evaluation the extent of the postponement suffered for each type of surgery and estimate the possible negative impact for patients. Study designSingle-center, retrospective, chart-review cohort study in the gynecology department of Hospital Foch. Comparison of all patients scheduled, postponed and operated during the first COVID lockdown (March 14, to May 11, 2020) versus the same period in 2019. Postponed surgeries were classified into 4 scheduling interval categories according to the Society of Gynecology Oncology (SGO) recommendations: urgent (without delay), semi-urgent (1–4 weeks), non-urgent (>4–12 weeks) and elective (>3 months) and evaluated to determine whether COVID-19-related delays of surgeries fell within guidelines. The potential “loss of chance” or medical risk associated with postponed surgeries was estimated according to a composite criterion including death, aggravation of expected tumor stages/grades in cancers, increase in surgical complexity compared to that initially planned, need for preoperative transfusions, start of morphine consumption during preoperative treatment for opiate-naive patients, additional hospitalization or consultations in emergency room and delay in treatment when surgery was urgent. ResultsDuring the 2020 French COVID lockdown, 61 patients had a surgical procedure and 114 were postponed; in the comparator 2019 group, 232 patients underwent surgical procedures, indicating an overall decrease of 65% of activity. Analysis of differences between the two years revealed a reduction of 64% in emergency procedures, 90% of functional pathologies, and 13% of cancers. According to SGO guidelines, the only type of surgical procedures that had excessive delay was the semi-urgent group, where time to surgery was 6.7 weeks [range 5.4–10 weeks] instead of the recommended interval of 1–4 weeks. Among postponed surgeries there were 10 patients (8.7%) with a potential “loss of chance” according to the composite criteria, all included in the semi-urgent group. ConclusionThe COVID 19 pandemic was responsible for a significant decrease of activity in the surgical department of Hospital Foch. Difficulty of rescheduling surgeries was responsible for an increased delay in semi-urgent operations. In almost 9% of postponed surgeries, there was a potential “loss of chance”, which likely represents only the tip of iceberg of collateral damages due to COVID 19 pandemic in this surgical unit. These data show the importance of continuing to treat pathologies requiring urgent or semi-urgent surgery during pandemics.

Hyperhemolysis Syndrome Following Pre-Operative Red Blood Cell Exchange

Abstract Introduction/Objective Pre-operative red blood cell exchange (RBCX) for patients with Sickle Cell Disease (SCD) is a category III indication. In our institution, RBCX is routinely performed pre-operatively when general anesthesia is necessary with the goal of HbS%&amp;lt;30 and reduction in adverse events related to general anesthesia. In the context of elective surgery, the risks and benefits of both the operation and any pre-operative transfusion must be discussed with the patient. Herein, we present an extreme case of Hyperhemolysis Syndrome resulting from a pre-operative RBCX. Methods/Case Report A 23-year-old transgender female with SCD (Hb S Lepore) treated with Hydroxyurea presented for elective breast augmentation for gender-affirmation. Her pre-operative plan included a RBCX. Her pre-exchange hemoglobin (Hb) and hematocrit (Hct) were 10.3 g/dL and 29.3%, respectively. Hb electrophoresis revealed HbS 52%, HbF 41.4%, HbA2 7.4%, and HbA was not detected. Type and Screen (T&amp;S) demonstrated O + blood group, with a negative antibody screen, and with no known historical alloantibodies. RBCX was performed using the Spectra Optia (TerumoBCT, Lakewood, CO, USA) with exchange volume of 1.9 L of group O+ RBCs, phenotypically matched for C, E, and K, an end Hct of 30% and an FCR of 30%. Her post-exchange Hb and Hct were 10.2g/dL and 29.5%, respectively. Hemoglobin fractionation revealed HbS 12% and HbA 73%. She underwent surgery without intraoperative complications. Two weeks post RBCX, her Hb had decreased to 5.3 g/dl, and her LDH and Total Bilirubin had increased to 253 ul and 1.8 mg/dl, respectively. A repeat T&amp;S drawn 8 days after RBCX revealed a positive antibody screen and direct antiglobulin test (DAT). Three new alloantibodies were identified: anti-Fya (present in plasma and eluate); anti-Jkb (present in plasma); anti-S (eluate). She was treated with IVIG, 0.4 g/Kg/day for 5 consecutive days and 2 doses of subcutaneous darbepoetin 100 mcg and subsequently discharged with close outpatient follow up. Her Hb returned to baseline at 11 g/dL, 48 days post RBCX. Results (if a Case Study enter NA) N/A Conclusion Pre-operative RBCX decreases morbidity in sickle cell patients undergoing general anesthesia. In the setting of elective surgery, patients must be counseled on the benefits and risks of surgery as well as the requisite RBCX. In our case, the patient developed multiple alloantibodies, with lifelong implications should she ever need future blood transfusions.

SP1.1.8Optimising anaemic patients for colorectal cancer surgery: implementation of day-case iron infusion pathway and closed loop audit of anaemia management

Abstract Aims Pre-operative anaemia is associated with increased mortality and morbidity in patients undergoing colorectal cancer (CRC) surgery. NICE recommends screening for and treating anaemia in this patient group. Our local guidelines reflect this and advocate the use of pre-operative IV iron provided to patients in the day-case unit. Through 2 audit cycles we assessed whether anaemic CRC patients were prescribed pre-operative iron infusion. Secondary outcome was the requirement of post-operative blood transfusion. Methods Data was collected between June-August 2019 (cycle 1) and January-February 2020 (cycle 2) for patients undergoing elective CRC surgery. Data collected included haemoglobin levels pre and post-operatively, pre-operative iron infusion and post-operative blood transfusion rates. Between the cycles education regarding anaemia management and further publicity of the iron infusion pathway took place within the department. Results In cycle 1 27.5% (11/40) of patients were anaemic; 18% (2/11) of these patients received appropriate iron infusion pre-operatively. In cycle 2 45.4% (20/44) of patients were anaemic; 60% (12/20) received iron infusion. 45% (5/11) of anaemic patients in cycle 1 had post-operative transfusion; none of these patients had pre-operative IV iron. In cycle 2 20% (4/20) of anaemic patient required post-operative transfusion; 3 out of 4 of these patients had not received pre-operative IV iron. Conclusions We have demonstrated how education and improved awareness of local services can increase rate of IV iron prescription and reduce the need for post-operative transfusion in anaemic CRC patients. However these is still room for improvement in management of anaemia within this patient group.

TP9.2.24Is preoperative ABO blood typing required in emergency appendicectomies?

Abstract Aims Intra-operative bleeding is very rarely a complication of laparoscopic appendicectomy. Despite this, it is often mandatory for any patient undergoing an emergency appendicectomy to have pre-operative ABO blood type sampling. This could be an unnecessary expense and may lead to patients being delayed for theatre. The aim of this study was to see how many patients who underwent an appendicectomy required a blood transfusion intra-operatively or within 30 days of their operation. Methods Data were collected retrospectively for patients of all ages who underwent an appendicectomy for suspected appendicitis at a single centre from March 2018 to May 2020. The primary outcome measure was intra-operative and post-operative blood transfusion up until 30 days after the operation. Results Over 26 months, 698 appendicectomies were performed. Preoperative ABO blood typing was performed in 95% (n = 663) of patients. Collectively, 1,305 blood samples were obtained at a combined total cost of £13,703 to the hospital. None of the patients required blood transfusion intra- or post-operatively. Pre-operative blood transfusion was performed in only three patients, all due to chronic anaemia. 21 (3%) patients were delayed in going to theatre whilst awaiting two valid ABO blood typing results. Conclusions Emergency appendicectomies very rarely experience complications associated with bleeding or requiring blood transfusion. Clinical guidelines should reflect this by avoiding recommendation of such tests in emergency appendicectomies, reducing delays to surgery and resulting in a more efficient allocation of financial and staff resources.

Association Between Preoperative Blood Transfusion and Postoperative Pulmonary Embolism

Association Between Preoperative Blood Transfusion and Postoperative Pulmonary Embolism

Development of a Preoperative Clinical Risk Assessment Tool for Postoperative Complications After Hysterectomy

To develop a preoperative risk assessment tool that quantifies the risk of postoperative complications within 30 days of hysterectomy. Retrospective analysis. Michigan Surgical Quality Collaborative hospitals. Women who underwent hysterectomy for gynecologic indications. Development of a nomogram to create a clinical risk assessment tool. Postoperative complications within 30 days were the primary outcome. Bivariate analysis was performed comparing women who had a complication and those who did not. The patient registry was randomly divided. A logistic regression model developed and validated from the Collaborative database was externally validated with hysterectomy cases from the National Surgical Quality Improvement Program, and a nomogram was developed to create a clinical risk assessment tool. Of the 41,147 included women, the overall postoperative complication rate was 3.98% (n=1638). Preoperative factors associated with postoperative complications were sepsis (odds ratio [OR] 7.98; confidence interval [CI], 1.98-32.20), abdominal approach (OR 2.27; 95% CI, 1.70-3.05), dependent functional status (OR 2.20; 95% CI, 1.34-3.62), bleeding disorder (OR 2.10; 95% CI, 1.37-3.21), diabetes with HbA1c ≥9% (OR 1.93; 95% CI, 1.16-3.24), gynecologic cancer (OR 1.86; 95% CI, 1.49-2.31), blood transfusion (OR 1.84; 95% CI, 1.15-2.96), American Society of Anesthesiologists Physical Status Classification System class ≥3 (OR 1.46; 95% CI, 1.24-1.73), government insurance (OR 1.3; 95% CI, 1.40-1.90), and body mass index ≥40 (OR 1.25; 95% CI, 1.04-1.50). Model discrimination was consistent in the derivation, internal validation, and external validation cohorts (C-statistics 0.68, 0.69, 0.68, respectively). We validated a preoperative clinical risk assessment tool to predict postoperative complications within 30 days of hysterectomy. Modifiable risk factors identified were preoperative blood transfusion, poor glycemic control, and open abdominal surgery.

Hidden blood loss in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgery: a retrospective study of 765 cases at a single centre

BackgroundIn scoliosis corrective surgery, total blood loss is composed of visible blood loss, including intraoperative haemorrhage and drainage, and hidden blood loss in which blood extravasates into the tissues and accumulates in the surgical field. The purpose of this study was to investigate hidden blood loss (HBL) and its potential risk factors in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgery and elucidate the influence of HBL on the necessity for postoperative blood transfusion.MethodsWe retrospectively studied adolescent idiopathic scoliosis patients undergoing posterior spine fusion for adolescent idiopathic scoliosis from January 2014 to December 2018 at our hospital. The patients’ demographics, blood loss-related parameters, surgeries and blood loss data were extracted. The association between patient characteristics and HBL was analyzed by Pearson or Spearman correlation analyses. Multivariate linear regression analysis was used to determine independent risk factors associated with HBL. Binary logistic regression analysis was used to analyze the influence of HBL on the necessity for postoperative blood transfusion.ResultsA total of 765 patients, of whom 128 were male and 637 were female (age range 10–18 years), were included in this study. The mean volume of HBL was 693.5 ± 473.4 ml, accounting for 53.9 % of the total blood loss. The multivariate linear regression analysis revealed that preoperative Hct (p = 0.003) and allogeneic blood transfusion (p < 0.001) were independent risk factors for HBL, while tranexamic acid (p = 0.003) was negatively correlated with HBL. Binary logistic regression analysis showed that HBL > 850 ml (P < 0.001, OR: 8.845, 95 % CI: 5.806–13.290) was an independent risk factor for the necessity for postoperative blood transfusion.ConclusionsSubstantial HBL occurred in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgeries. Allogeneic blood transfusion and preoperative Hct were independent risk factors for HBL, while tranexamic acid was negatively related to HBL. HBL and its influencing factors should be considered when planning perioperative transfusion management. Patients with HBL greater than 850 ml should be closely monitored in cases of postoperative anaemia.Level of evidenceLevel III.

Predicting Early Extubation After Liver Transplantation: External Validation and Improved Generalizability of a Proposed Fast-track Score.

Early extubation of liver transplantation recipients is a cornerstone of fast-track (FT) pathways. Identifying suitable candidates has previously been accomplished using perioperative variables to develop a FT probability score. The objective of this study was to externally validate a proposed FT score. Following Research Ethics Board approval, data were extracted on liver transplants conducted at a single center from 2009 to 2017. Data extracted included patient characteristics, intraoperative variables, and postoperative outcome variables. The proposed FT score utilized 9 variables: age, gender, body mass index, model of end-stage liver disease, retransplant, preoperative hospital admission, blood transfusion, operative time, and vasopressor use. We calculated the FT score in our cohort, and assessed the discrimination and calibration of the model. Score performance was explored by subgroup analyses, customization and altering the outcome definition. The FT score was found to predict higher rates of successful FT than was observed in the external cohort (n = 1385) and had reduced discrimination (area under the receiver operating curve, 0.711; 95% confidence interval, 0.682-0.741) compared with the original internal validation cohort (area under the receiver operating curve, 0.830; 95% confidence interval, 0.789-0.871; P < 0.0001). Discrimination was improved by customizing the transfusion (P < 0.0001) components of the simplified score or by level 1 customization of all regression model coefficients (P < 0.0001). A time-based definition of FT (early extubation) did not alter the accuracy of the prediction score (P = 0.914), improving the model's generalizability. The proposed FT score may help identify patients suitable for early extubation and FT pathways after liver transplantation in conjunction with clinical judgment.

Craniosynostosis With Preoperative Iron Supplementation Exposure: A Retrospective Cohort Study Examining Preoperative Iron Supplementation and Transfusion Practice in a National Paediatric Craniofacial Centre.

Blood loss and subsequent transfusion are key concerns in the surgical management of craniosynostosis, and have been associated with increased morbidity, requirement for intensive care admission and increased length of hospital stay. Patient blood management guidelines advocate treatment of anemia before elective surgical procedures where significant blood loss is anticipated. At present there is little evidence in the literature investigating the clinical value of this practice in pediatric craniofacial surgery. The authors examined the effect of preoperative oral iron supplementation on blood loss and transfusion rates in a national pediatric craniofacial unit. A total of 157 patients were included in a retrospective and prospective observational cohort study conducted between July 2011 and November 2016. Eighty-five (85) patients included in the preoperative iron supplementation group were prescribed oral ferrous fumarate before total cranial vault reconstruction, frontal-orbital advancement or extended strip cranial vault remodeling procedures. This cohort was retrospectively compared to seventy-two (72) consecutive patients who did not receive iron supplementation. Calculated blood loss was 51.3 mL/kg in the intervention group, and 56.65 mL/kg in the control group. Transfusion rate and mean volumes for the intervention group were 85.9% and 25 mL/kg. The control group had transfusion rate of 86.1% with mean transfused volume of 24.7 mL/kg. These differences were not statistically significant. Intraoperative tranexamic acid was associated with significantly reduced transfusion volumes overall. This study did not show a statistically significant benefit to preoperative iron supplementation. Secondary outcomes of this study showed a statistically significant difference in estimated versus calculated intraoperative blood loss. Further research in to specific iron supplementation protocols is indicated.

Preoperative risk factors of incisional surgical site infection in severe or intractable ulcerative colitis.

The present study explored preoperative risk factors (predictors) of incisional surgical site infection (I-SSI) in severe or intractable ulcerative colitis (UC). This was a retrospective study of 230 consecutive patients who underwent primary surgery for UC. Patients whose surgical indications were UC with cancer or dysplasia were excluded. SSI was defined as an infection according to the Centers for Disease Control and Prevention Guidelines. Preoperative variables were examined by univariate, receiver operating characteristic curve, and multivariate analyses. We analyzed 208 patients in this study. In a multivariate logistic analysis, C-reactive protein (CRP) ≥ 1.7mg/dl [odds ratio (OR) 5.35; 95% confidence interval (CI) 1.50-19.06; p = 0.01), albumin ≤ 2.4g/dl (OR 5.77; 95% CI 1.41-23.57; p = 0.02), and preoperative blood transfusion (OR 3.21; 95% CI 1.04-9.96; p = 0.04) were predictors of I-SSI. Patients with all predictors had a more than 50% incidence of I-SSI, a higher incidence of all severe complications (13.6% vs. 3.2%; p = 0.02), and a longer postoperative hospital stay (19.5 vs. 17.0days, p = 0.04) than the other patients. CRP ≥ 1.7mg/dl, albumin ≤ 2.4g/dl, and transfusion are predictors of I-SSI in severe or intractable UC. Clinician should carefully evaluate the surgical options before these predictors appear.

Incidence, Predictors and Outcomes of Delirium in Complicated Type B Aortic Dissection Patients After Thoracic Endovascular Aortic Repair.

PurposeThe present study aimed to investigate the incidence and predictors of post-operative delirium (POD) in patients with complicated type B aortic dissection (TBAD) undergoing TEVAR with/without concomitant procedures and to assess the association of POD with early and follow-up outcomes.MethodsA retrospective single-center cross-sectional analysis was conducted using a prospectively maintained database from 2010 to 2017. Outcomes were postoperative clinical outcomes, early and follow-up survival.ResultsA total of 517 complicated TBAD patients were enrolled. POD was observed in 13.3% (69/517) patients and was associated with increased hospital length of stay (LOS) and hospital costs (P< 0.001 for both). Besides, POD was found to be an independent risk factor for prolonged ICU stay (odds ratio [OR] 4.39, 95% confidence interval [CI] 2.40–8.01, P< 0.001) and early death (OR 4.42, 95% CI 1.26–15.54, P= 0.020). Predictors of POD were hybrid procedure (OR 2.17, 95% CI 1.20–3.92, P= 0.010), the use of benzodiazepine (OR 1.86, 95% CI 1.07–3.23, P= 0.027) or quinolone (OR 2.35, 95% CI 1.26–4.38, P= 0.007), creatinine >2 mg/dL (OR 3.25, 95% CI 1.57–6.72, P= 0.001) and preoperative blood transfusion (OR 3.31, 95% CI 1.76–6.21, P< 0.001). After a median follow-up of 73.6 months, POD remained as an independent indicator for follow-up mortality (hazard ratio [HR] 2.40, 95% CI 1.31–4.38, P= 0.005) after adjusting potential confounders.ConclusionPOD after TEVAR has an incidence of around 13% and could profoundly increase the in-hospital LOS, hospital costs, as well as the early and follow-up mortality. A series of risk factors, including hybrid procedure, the use of benzodiazepine or quinolone, creatinine >2 mg/dL and preoperative blood transfusion, were identified as independent risk factors for POD. Effective risk-stratification and patient-tailored management strategy should be developed to reduce the incidence of POD.

Expert consensus on the use of human serum albumin in critically ill patients.

Expert consensus on the use of human serum albumin in critically ill patients.

Blunt Cardiac Injuries That Require Operative Management: A Single-Center 7-Year Experience

Purpose Blunt cardiac injuries (BCI) have a wide clinical spectrum, ranging from asymptomatic myocardial contusion to cardiac rupture and death. BCIs rarely require surgical intervention, but can be rapidly fatal, requiring prompt evaluation and surgical treatment in some cases. The aim of this study was to identify potential factors associated with in-hospital mortality after surgery in patients with BCI. Methods The medical records of 15 patients who had undergone emergency cardiac surgery for BCI between January 2014 and August 2020 were retrospectively reviewed. We included trauma patients older than 18 years admitted to Regional Trauma Center, Gachon University Gil Medical Center during the study period. Clinical and laboratory variables were compared between survivors and non-survivors. Results Non-survivors showed a significantly higher Injury Severity Score (p=0.001) and Abbreviated Injury Scale in the chest region (p=0.001) than survivors. American Association for the Surgery of Trauma-Organ Injury Scale Grade V injuries were significantly more common in non-survivors than in survivors (p=0.031). Non-survivors had significantly more preoperative packed red blood cell (PRBC) transfusions (p=0.019) and were significantly more likely to experience preoperative cardiac arrest (p=0.001) than survivors. Initial pH (p=0.010), lactate (p=0.026), and base excess (BE; p=0.026) levels showed significant differences between the two groups. Conclusions Initial pH, lactate, BE, ventricular injury, the amount of preoperative PRBC transfusions, and preoperative cardiac arrest were potential predictors of in-hospital mortality.

Nomogram to predict postoperative infectious complications after surgery for colorectal cancer: a retrospective cohort study in China

BackgroundPostoperative infectious complications (ICs) after surgery for colorectal cancer (CRC) increase in-hospital deaths and decrease long-term survival. However, the methodology for IC preoperative and intraoperative risk assessment has not yet been established. We aimed to construct a risk model for IC after surgery for CRC.MethodsBetween January 2016 and June 2020, a total of 593 patients who underwent curative surgery for CRC in Chengdu Second People’s Hospital were enrolled. Preoperative and intraoperative factors were obtained retrospectively. The least absolute shrinkage and selection operator (LASSO) method was used to screen out risk factors for IC. Then, based on the results of LASSO regression analysis, multivariable logistic regression analysis was performed to establish the prediction model. Bootstraps with 300 resamples were performed for internal validation. The performance of the model was evaluated with its calibration and discrimination. The clinical usefulness was assessed by decision curve analysis (DCA).ResultsA total of 95 (16.0%) patients developed ICs after surgery for CRC. Chronic pulmonary diseases, diabetes mellitus, preoperative and/or intraoperative blood transfusion, and longer operation time were independent risk factors for IC. A prediction model was constructed based on these factors. The concordance index (C-index) of the model was 0.761. The calibration curve of the model suggested great agreement. DCA showed that the model was clinically useful.ConclusionSeveral risk factors for IC after surgery for CRC were identified. A prediction model generated by these risk factors may help in identifying patients who may benefit from perioperative optimization.

Feasibility and Safety of Retrograde Radical Cystectomy under Combined Spinal and Epidural Anesthesia in High-risk and Elderly Patients. A Single Surgeon Experience

Purpose: The purpose of the study is to study feasibility and safety of retrograde radical cystectomy (RC) under regional anesthesia (RA) in high-risk and elderly patients of muscle invasive bladder carcinoma. Materials and Methods: This study was an observational study, conducted in the department of urology, SKIMS, Kashmir, India, from 2012 to 2020. All patients underwent retrograde RC under RA. Results: Thirty-seven patients were operated with median follow-up period of 32 months and included 30 male and 7 female patients with median age of 74.5 years (70–83 years). The American Society of Anesthesiologists score was II in 20 patients, III in 15 patients, and IV in 2 patients. All the patients included in study had significant comorbidities. All patients were anemic and required preoperative blood transfusions for optimization. Total blood loss ranged from 200 to 900 ml (mean: 400 ml). Bilateral internal iliac artery was ligated preemptively in all patients. Total transfusion required ranged from one to six units (mean: 2 units). Number of lymph nodes removed ranged from 15 to 35 (mean: 20). Total peritoneal exposure time ranged from 0 to 70 min (mean: 50 min). None of the patient needed intensive care postoperatively. Gastrointestinal tract (GIT) recovery time ranged from 1 to 4 days (mean of 1.5 days). Total hospital stay ranged from 7 to 15 days (mean: 9 days). On follow-up, one patient had stent (feeding tube) fracture, and the residual fragment was managed by antegrade approach. One patient had ureteroileal anastomotic stricture which was managed by refashioning of the anastomosis (Bricker to Wallace). One patient had stomal stenosis with features of recurrent urinary tract infections and underwent refashioning of stoma with stabilization of renal function. Conclusion: To circumvent the need of postoperative ventilation, intensive care unit admission, and prolonged hospital stay, we advocate retrograde extraperitoneal RC under combined RA (CRA) as preferred approach of surgical intervention in high-risk and elderly patients with little abdominal organ disturbance and early bowel recovery.

Risk Factors for 30-Day Mortality After Head and Neck Microsurgical Reconstruction for Cancer: NSQIP Analysis.

ObjectiveTo identify the incidence and risk factors for 30-day postoperative mortality after microsurgical head and neck reconstruction following oncological resection.Study DesignRetrospective case-control study.SettingAmerican College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.MethodsMicrosurgical head and neck reconstructive cases were identified from 2005 to 2018 using Current Procedural Terminology codes and oncologic procedures using the International Classification of Disease 9 and 10 codes. The outcome of interest was 30-day mortality.ResultsThe 30-day postoperative mortality rate was 1.2%. Univariate logistic regression analysis identified the following associations: age >80 years, hypertension, poor functional status, preoperative wound infection, renal insufficiency, malnutrition, anemia, and prolonged operating time. Multivariable logistic regression models were used to stratify further by the degree of malnutrition and anemia. Hematocrit <30% was found to be an independent risk factor for 30-day postoperative mortality (odds ratio [OR] = 9.59, confidence interval [CI] 2.32-39.65, P < .1) with albumin <3.5 g/dL. This association was even stronger with albumin <2.5 g/dL (OR = 11.64, CI 3.06-44.25, P < .01). One-third of patients (36.6%) had preoperative anemia, of which less than 1% required preoperative transfusion, although one-quarter (24.6%) required intraoperative or 72 hours postoperative transfusion.ConclusionsPreoperative anemia is a risk factor for 30-day postoperative mortality. This association seems to get stronger with worsening anemia. Identification and optimization of such patients preoperatively may mitigate the incidence of 30-day postoperative mortality.

First year of the COVID-19 pandemic influence on bladder cancer patients in one single academic urological center from North-Eastern Romania

The COVID-19 pandemic created an unprecedented situation who made health systems to reorganize their resources and redeploy staff away from routine diagnostic, treatment and follow‐up services. Material and methods:&nbsp; have studied retrospective the medical files of bladder cancer patients referred to our clinic between 1st of March 2019- 28 of February 2020 (group A) compared with those referred between 1st of March 2020- 1st of March 2021 (group B). A total of 640 patients were included, 486 (75.94%) males and 154 (24.06%) females, aged between 22 and 92 years, with a mean age of 69.12 years (SD+/-9.62). Group A had 408 (63.75%) patients while group B 232 (36.25%). Results: We have noticed that anemia was significantly more often in group B (p=0.032), this has led to a higher necessity of preoperative blood transfusion (p=0.039) but with no differences regarding inflammatory syndrome or kidney failure incidence. Also, the hospitalization period (p=0.001) and the time from admission to surgery have been significantly shorter in group B (p=0.05). Conclusions: By trying to avoid hospitalization many patients are admitted with a poorer biological status. In addition, many bladder cancer cases will go undetected and untreated and once the pandemic has passed, we will face an excess in cancer-related mortality.

Friend or foe? Feeding tube placement at the time of pancreatoduodenectomy: propensity score case-matched analysis.

The role of concomitant gastrostomy or jejunostomy feeding tube (FT) placement during pancreatoduodenectomy (PD) and its impact on patient outcomes remain controversial. NSQIP database was surveyed for patients undergoing PD between 2014 and 2017. FT placement was identified using CPT codes. Propensity scores were used to match the two groups (1:1) on baseline characteristics and intraoperative variables including pancreas specific ones (duct size, gland texture, underlying disease, wound class, use of wound protector, drain placement, type of pancreatic reconstruction and vascular reconstruction). Outcomes were compared. Finally, a subset analyses for patients with delayed gastric emptying (DGE) or postoperative pancreatic fistula (POPF) were performed. Out of 15,224 PD, 1,104 (7.5%) had FT. POPF and DGE rates were 17% and 18%, respectively, for the entire cohort. Feeding jejunostomy was the most placed FT (88.2%). Patients with FT placement were more likely to be older (mean, 65.8 vs. 64.6 y), smokers (22.6% vs. 17.8%) who had preoperative weight loss (22.5% vs. 15.3%), ASA class ≥ 3 (80.8% vs. 77.5%), preoperative transfusion (1.5% vs. 0.84%), chemotherapy (22.8% vs. 17.5%), and radiation (14.5% vs. 6.8%, p < 0.05). The matched cohort included 880 patients in each group with completely balanced preoperative and intraoperative characteristics. In the matched cohort, patients with FT placement had higher overall morbidity (52.2% vs. 44.3%, p = 0.001), major morbidity (28.4% vs. 22.5%, p = 0.004), organ/space infection (14.4% vs. 10.9%, p = 0.026), re-operation (8.6% vs. 5.1%, p = 0.003), DGE (26.8% vs. 16.4%, p < 0.001), and longer mean hospital length of stay (12.9 vs. 11.2days, p = 0.001) than those without FT. There was no difference in mortality (1.7% vs. 2.2%, p = 0.488) or readmission rate (20.2% vs. 17.2%, p = 0.099). In patients with DGE and POPF, FT placement was not associated with morbidity, mortality, length of stay, or readmission rate (p > 0.05). Patients with FT placement during PD tend to have higher postoperative morbidity and delayed recovery.

Preoperative risk factors for postoperative blood transfusion after hip fracture surgery: establishment of a nomogram

BackgroundThis study aimed to explore the preoperative risk factors related to blood transfusion after hip fracture operations and to establish a nomogram prediction model. The application of this model will likely reduce unnecessary transfusions and avoid wasting blood products.MethodsThis was a retrospective analysis of all patients undergoing hip fracture surgery from January 2013 to January 2020. Univariate and multivariate logistic regression analyses were used to evaluate the association between preoperative risk factors and blood transfusion after hip fracture operations. Finally, the risk factors obtained from the multivariate regression analysis were used to establish the nomogram model. The validation of the nomogram was assessed by the concordance index (C-index), the receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and calibration curves.ResultsA total of 820 patients were included in the present study for evaluation. Multivariate logistic regression analysis demonstrated that low preoperative hemoglobin (Hb), general anesthesia (GA), non-use of tranexamic acid (TXA), and older age were independent risk factors for blood transfusion after hip fracture operation. The C-index of this model was 0.86 (95% CI, 0.83–0.89). Internal validation proved the nomogram model’s adequacy and accuracy, and the results showed that the predicted value agreed well with the actual values.ConclusionsA nomogram model was developed based on independent risk factors for blood transfusion after hip fracture surgery. Preoperative intervention can effectively reduce the incidence of blood transfusion after hip fracture operations.