Significant Difference In Transfusion Requirements Research Articles

Radiation cystitis in acute admissions for haematuria.

To assess the outcomes of patients with haematuria from radiation cystitis admitted to Christchurch Hospital's Urology Service and identify treatment differences and hospitalisation trends. From November 2021 to January 2023, a retrospective analysis of 144 acute haematuria admissions was conducted. Data covered demographics, diagnosis, surgeries, complications and hospital stay length. Predictive factors for admissions and surgical interventions were explored. Of the 144 admissions, 22 (15.3%) were diagnosed with radiation cystitis. The management strategies for radiation cystitis and non-radiation cystitis patients showed no significant differences in transfusion requirements, anti-bleeding medication usage (finasteride and/or tranexamic acid), or the need for acute or elective surgery. The average length of stay for admission was similar between the groups (radiation cystitis: 3.7 days, non-radiation cystitis: 3.5 days, p<0.05), but the readmission rate was significantly higher for radiation cystitis patients (59.1% vs 25.4%, p<0.01). The management and hospital stay duration were similar for both cohorts; radiation cystitis patients faced increased readmissions, underscoring the necessity for rigorous monitoring and subsequent care. Upcoming research should target refining early interventions and management methods.

Practice patterns of ABO-matching for cryoprecipitate and patient outcomes after ABO-compatible versus incompatible cryoprecipitate.

This sub-study of the FIBRES trial sought to examine the patterns of ABO-compatible cryoprecipitate administration and to identify adverse consequences of ABO-incompatible cryoprecipitate. This was a post hoc analysis of data collected from the FIBRES randomized clinical trial comparing fibrinogen concentrate with cryoprecipitate in the treatment of bleeding related to hypofibrinogenemia after cardiac surgery. The primary outcome was the percentage of administered cryoprecipitate that was ABO-compatible. Secondary outcomes were adverse events at 28 days. A follow-up survey was distributed to the FIBRES participating sites to examine the rationale behind the identified cryoprecipitate ABO-matching practice patterns. A total of 363 patients were included: 53 (15%) received ABO-incompatible cryoprecipitate and 310 (85%) received ABO-compatible cryoprecipitate. There was an increased incidence of post-operative anaemia in the ABO-incompatible group (15; 28.3%) in comparison to the ABO-compatible (44; 14.2%) group (p=0.01) at 28 days, which was unrelated to haemolysis, without a significant difference in transfusion requirement. In the multivariable logistic regression models accounting for clustering by site, there was no observed statistically significant association between the administration of ABO-incompatible cryoprecipitate and any other adverse outcomes. Nine out of 11 sites did not have a policy requiring ABO-matched cryoprecipitate. This sub-study demonstrated that most cryoprecipitate administered in practice is ABO-compatible, despite the absence of guidelines or blood bank policies to support this practice. A signal towards increased risk of post-operative anaemia may be explained by higher rates of urgent surgery (vs. elective) in the ABO-incompatible group. Future studies should prospectively examine the impact of ABO-compatible versus incompatible cryoprecipitate to conclusively establish if there is a meaningful clinical impact associated with the administration of ABO-incompatible cryoprecipitate.

Assessment of Video Capsule Endoscopy in the Management of Acute Gastrointestinal Bleeding During the COVID-19 Pandemic

Evaluation of acute gastrointestinal (GI) bleeding using invasive endoscopic procedures comprising the standard of care (SOC)-upper endoscopy and colonoscopy-can expose the endoscopy staff to SARS-CoV-2. Video capsule endoscopy (VCE) does not generate aerosols and only requires 1 person to manage the procedure. To examine the safety of VCE for the initial evaluation of GI bleeding at the peak of the COVID-19 pandemic to identify signs of active bleeding while minimizing patient and personnel exposure, saving personal protective equipment, and avoiding invasive or unnecessary procedures. A multicenter (UMass Memorial Medical Center and Louisiana State University Health Sciences Center) retrospective cohort study including 146 patients with COVID-19 who received VCE as the first-line diagnostic modality was conducted from March 15 to June 15, 2020, compared with SOC in January 2020 for evaluation of GI bleeding. The association between treatment and outcomes was estimated using multivariable regression adjusting for potential confounders. Propensity score matching was used to verify the results. The primary end point was detection of active bleeding or stigmata of recent bleeding. Secondary end points included the number of patients requiring any invasive procedures, number of additional procedures, rates of rebleeding and rehospitalization, transfusion requirements, and mortality. Among 146 patients, 92 (63.0%) were men; mean (SD) age was 64.93 (14.13) years in the COVID-19 group and 61.33 (13.39) years in the SOC group. Active bleeding or stigmata of recent bleeding was observed in 44 (59.5%) patients in the COVID-19 group compared with 18 (25.0%) in the SOC group (adjusted odds ratio, 5.23; 95% CI, 2.23 to 12.27). Only 36 patients (48.7%) in the COVID-19 group required any invasive procedure during the hospitalization compared with 70 (97.2%) in the SOC group (adjusted odds ratio, 0.01; 95% CI, 0.001 to 0.08). The mean (SD) number of invasive procedures was 0.59 (0.77) per patient in the COVID-19 group compared with 1.18 (0.48) per patient in the SOC group (adjusted difference, -0.54; 95% CI, -0.77 to -0.31). Both approaches appeared to be safe and there was no significant difference in transfusion requirements, rebleeding, rehospitalization, or in-hospital mortality. No mortality was attributed to GI bleeding in either group. In this cohort study, first-line diagnostic evaluation of acute GI bleeding using VCE appeared to be a safe and useful alternative to the traditional approach of upper endoscopy and colonoscopy. Use of VCE was associated with increased detection of active bleeding and a reduced number of invasive procedures and unnecessary exposure of personnel to SARS-CoV-2 and use of personal protective equipment.

A Single-Center Retrospective Review of Perioperative Complications and Reoperation Rates Between Open Cranial Vault Remodeling and Distraction Osteogenesis for Unilateral Coronal Craniosynostosis.

Unilateral coronal craniosynostosis (UCS) is the third most prevalent form of craniosynostosis. Traditional treatment of UCS has been achieved with fronto-orbital advancement and cranial vault remodeling (FOAR), but utilization of cranial distraction osteogenesis (DO) techniques has increased. This study aims to compare perioperative complications and reoperation trends in FOAR versus DO techniques at a single institution. An Institutional Review Board-approved retrospective review was performed from January 1999 to November 2018 at a single institution. Patients were those that have undergone FOAR or DO with an anterior rotational flap technique as previously described. Indications for secondary procedures included: contour deformities, relapse, surgical site infection, and persistent cranial defects. Eighty-one patients with UCS were identified, 64 patients underwent FOAR and 17 patients underwent DO. When perioperative characteristics were compared, patients who underwent DO were younger in age, however, there was no significant difference in transfusion requirement or length of stay between patient cohorts. Surgery time was increased in DO patients. When perioperative complications were compared, more intraoperative dural tears were observed in the FOAR cohort. When unplanned reoperation rates were compared, patients who had undergone FOAR had a statistically significant higher reoperation rates at 5 years of follow up. When including routine distractor removal as a reoperation, reoperative rate was increased in the DO cohort. No difference in reoperation rates was noted at 5 years following index operation. The safety profile of DO is similar to that of traditional FOAR techniques for treatment of UCS. Longer-term follow-up studies are needed to elucidate whether outcomes are durable, but the unplanned reoperation rate in DO is less than that of FOAR at 5 years and presents several advantages that warrants its use in patients with UCS.

S0590 Video Capsule Endoscopy as First Procedure for Acute Gastrointestinal Bleeding: An Approach to Minimizing Exposure to SARS-CoV-2 and Conserving Resources

INTRODUCTION: Video capsule endoscopy (VCE) has been proposed as an alternative triaging tool for diagnosis of hematemesis and non-hematemesis (GIB). Randomized controlled trials have shown higher detection rates of bleeding with VCE when used as the first procedure compared with standard of care (SOC). This approach been shown to be safe, and well tolerated. VCE is particularly suitable for the diagnosis of GIB in suspected/established SARS-CoV-2 (COVID) patients as it requires minimal patient contact (one staff person) to set up, and it avoids aerosolization and sedation. We used VCE as the first diagnostic modality in hemodynamically stable patients with GIB. Here we report the outcomes of the first 50 patients undergoing VCE in the COVID era as compared to 57 historical controls in the pre-COVID era. METHODS: Hemodynamically stable patients with suspected GIB/severe anemia admitted to our hospital between March and May 2020 and who underwent VCE as the first line diagnostic modality composed the experimental group. Demographic, clinical, and outcome data was collected and analyzed. The control group comprised of patients undergoing evaluation for GIB by SOC at our hospital in January 2020. Continuous variables were compared using Student t-test. Categorical variables were compared using Fisher’s exact test. RESULTS: Patients in both groups had similar baseline characteristics, except COVID cohort was slightly older. More patients in the COVID cohort presented with melena and fewer presented with hematochezia as their manifestation of their GIB. This difference was only significant for hematochezia. Bleeding could be localized in 38 (76%) of the COVID cohort patients as compared to 36 (63%) of the historical controls using the first diagnostic modality, P > 0.05 significant. Only 22 (44%) of the VCE patients underwent additional invasive diagnostic/therapeutic maneuvers and the majority were spared more invasive testing. Only 13 (26%) of the VCE patients, as compared to 47 (82%) of the historical controls underwent upper endoscopy for evaluation of GIB. There was no significant difference in transfusion requirements, degree of hemoglobin drop, in-hospital mortality, re-admission or rebleeding rates between the two groups. CONCLUSION: VCE appears to be a safe alternative to traditional diagnostic evaluation of GIB in the era of COVID. It reduced risk of exposure of staff to endoscopic aerosols, conserved personal protective equipment and reduced staff utilization.Table 1Table 2

Overall Postoperative Morbidity and Pancreatic Fistula Are Relatively Higher after Central Pancreatectomy than Distal Pancreatic Resection: A Systematic Review and Meta-Analysis.

Objective To compare the intraoperative and postoperative outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP). Methods A systematic literature search was performed on electronic databases from MEDLINE, Embase, and PubMed from 1998 to 2018. Statistical analysis and meta-analysis were performed using statistics/data analysis (Stata®) software, version 12.0 (StataCorp LP, College Station, Texas 77845, USA). Dichotomous variables were analyzed by estimation of relative risk (RR) with a 95 percent (%) confidence interval (CI) and continuous variables were analyzed by standardized mean differences (SMD) with 95% CI. Results Twenty-four studies with 593 CP and 1226 DP were included in the meta-analysis. CP had significantly longer operation time (SMD: 1.03; 95% CI 0.62 to 1.44; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.01). Estimated blood loss was significantly lower in CP (SMD: −0.34; 95% CI −0.58 to −0.09; P = 0.007). Overall postoperative morbidity (RR: 1.30; 95% CI: 1.13 to 1.50; P < 0.001), overall pancreatic fistula (RR: 1.41; 95% CI: 1.20 to 1.66; P < 0.001), clinically relevant fistula (RR: 1.64; 95% CI: 1.25 to 2.16; P < 0.001), and postoperative hemorrhage (RR: 1.90; 95% CI: 1.18 to 3.06; P < 0.05) were all significantly higher after CP. On long-term follow-up, DP patients were more likely to have postoperative exocrine (RR: 0.56; 95% CI: 0.37 to 0.84; P < 0.05) and endocrine (RR: 0.27; 95% CI: 0.18 to 0.40; P < 0.001) insufficiency. There was no statistically significant difference in transfusion requirement, postoperative mortality, reoperation, and tumor recurrence. Conclusion CP is associated with significantly higher morbidity and clinically relevant pancreatic fistula. CP should only be reserved for selected patients who require postoperative pancreatic function preservation.

Are We Choosing Mobilization Regimens for Autologous Stem Cell Transplantation in Multiple Myeloma Wisely?: A Single Centre Comparison of GCSF+/-Plerixafor Vs Cyclophosphamide/GCSF+/- Plerixafor

Background: Autologous stem cell transplantation (ASCT) as consolidation post induction is standard of care for eligible multiple myeloma patients. Multiple strategies are employed for mobilization of stem cells in ASCT. Cyclophosphamide/GCSF is an effective standard regimen. However there are reported toxicities associated with cyclophosphamide including risk of febrile neutropenia. Since plerixafor was introduced in Canada, this mobilization agent has been increasingly used as needed with GCSF at Kingston Health Science Centre (KHSC), with elimination of cyclophosphamide. There is however high cost associated with plerixafor. To date, there is no standard mobilization regimen across Canada. This retrospective study evaluates mobilization and ASCT outcomes of multiple myeloma patients who had undergone stem cell mobilization with GCSF+/-plerixafor (GP) vs cyclophosphamide/GCSF+/-plerixafor (CyGP) at KHSC. The goal is to analyze the efficacy of each regimen balanced with adverse events to guide optimal mobilization regimen choice. Method: Patient with multiple myeloma who had ASCT at KHSC were selected consecutively based on date of ASCT in a reverse chronological order starting from Jan 2019. From Oct 2015 to March 2018, CyGP was the mobilization regimen used at KHSC. From March 2017 to January 2019, cyclophosphamide was eliminated and GP was used. Both groups could have received plerixafor as needed based on Cancer Care Ontario funding criteria such as failure to achieve target CD34+ cell count. Retrospective chart review was conducted to collect data on demographics, plerixafor use, days of apheresis, total cell collected, rate of febrile neutropenia, length of transplant hospital stay, time to engraftment, and transfusion requirement. Chi-Square, t-test, or Mann Whitney methods were used for test of statistical significance where appropriate. Results: Total 97 patients were included with 47 in the GP group and 50 in the CyGP group (Table 1). Average age was 64 and 63 respectively. 32% of patients in GP group and 36% of CyGP group required plerixafor rescue. No difference in the number of apheresis days were noted in the two groups. Total cell collection was significantly higher in the CyGP group (P&lt;0.001). Day 1 and 2 cell collections were also significantly higher in the CyGP group (P&lt;0.05) (Fig 1). The cell dose target varied in the CyGP group due to changing practices over time which is a confounding factor. There were no cases of febrile neutropenia in the GP group and 3 cases in the CyGP group (P=0.243). All 3 febrile neutropenia patients required hospitalization with 1 requiring ICU. There was no clinically significant difference in transfusion requirement during ASCT (Fig 2). Median time to engraftment of neutrophil and platelet after ASCT were less by 1 day in the CyGP group (P&lt;0.05) (Fig 3), although there was no difference in length of transplant hospital stay. Conclusions: Stem cell mobilization with CyGP resulted in significantly higher total collection cell count, and more efficient collection with higher yield on the first 2 days of apheresis. However, there was no difference in the total number of apheresis days. It also did not lead to less plerixafor usage and was associated with possibly higher rate of febrile neutropenia. There was no clinically significant difference in transplant outcomes in terms of transfusion support required, days to engraftment, or length of hospitalization for ASCT. Mobilization with GCSF+/-plerixafor without cyclophosphamide is a non-inferior regimen. Disclosures Bhella: Celgene: Consultancy, Honoraria.

Thrombelastometry guided blood-component therapy after cardiac surgery: a randomized study

BackgroundSignificant bleeding is a well known complication after cardiac surgical procedures and is associated with worse outcome. Thrombelastometry (ROTEM®) allows point-of-care testing of the coagulation status but only limited data is available yet. The aim was to evaluate the ROTEM®-guided blood component therapy in a randomized trial.MethodsIn case of significant postoperative bleeding (> 200 ml/h) following elective isolated or combined cardiac surgical procedures (including 14% re-do procedures and 4% requiring circulatory arrest) patients were randomized to either a 4-chamber ROTEM®-guided blood-component transfusion protocol or received treatment guided by an algorithm based on standard coagulation testing (control). One hundred four patients (mean age: 67.2 ± 10.4 years, mean log. EuroSCORE 7.0 ± 8.8%) met the inclusion criteria. Mean CPB-time was 112.1 ± 55.1 min., mean cross-clamp time 72.5 ± 39.9 min.ResultsBaseline demographics were comparable in both groups. Overall there was no significant difference in transfusion requirements regarding red blood cells, platelets, plasma, fibrinogen or pooled factors and the re-thoracotomy rate was comparable (ROTEM®: 29% vs. control: 25%). However, there was a trend towards less 24-h drainage loss visible in the ROTEM®-group (ROTEM®: 1599.1 ± 834.3 ml vs. control: 1867.4 ± 827.4 ml; p = 0.066). In the subgroup of patients with long CPB-times (> 115 min.; n = 55) known to exhibit an increased risk for diffuse coagulopathy ROTEM®-guided treatment resulted in a significantly lower 24-h drainage loss (ROTEM®: 1538.2 ± 806.4 ml vs. control: 2056.8 ± 974.5 ml; p = 0.032) and reduced 5-year mortality (ROTEM®: 0% vs. control: 15%; p = 0.03).ConclusionIn case of postoperative bleeding following cardiac surgical procedures a treatment algorithm based on “point-of-care” 4-chamber ROTEM® seems to be at least as effective as standard therapy. In patients with long CPB-times ROTEM®-guided treatment may result in less bleeding, a marked reduction in costs and long-term mortality.Trial registrationGerman Clinical Trials Register, TRN: DRKS00017367, date of registration: 05.06.2019, ‘retrospectively registered’.

The effect of different dosage regimens of tranexamic acid on blood loss in bimaxillary osteotomy: a randomized, double-blind, placebo-controlled study

The purpose of this study was to compare the effects of three dosage regimens of intravenous tranexamic acid and normal saline placebo on blood loss and the requirement for transfusion during bimaxillary osteotomy. A prospective, randomized, double-blind, placebo-controlled study was performed. Eighty patients scheduled for elective bimaxillary osteotomy were divided into four groups: a placebo group and three groups receiving a single dose of tranexamic acid 10, 15, or 20mg/kg body weight after the induction of anaesthesia. Demographic data, the anaesthetic time, the operative time, and the experience of the surgical team were similar in the four groups. Patients receiving placebo had increased blood loss compared to those receiving tranexamic acid. No significant difference in blood loss was found among those who received 10, 15, or 20mg/kg body weight of tranexamic acid. There was no significant difference in transfusion requirement, amount of 24-h postoperative vacuum drainage, length of hospital stay, or complications among the four groups. Prophylactic tranexamic acid decreased bleeding during bimaxillary osteotomy. Of the three dosages of tranexamic acid studied, the most efficacious and cost-effective dose to reduce bleeding was 10mg/kg body weight.

Pilot validation of an individualised pharmacokinetic algorithm for protamine dosing after systemic heparinisation for cardiopulmonary bypass.

This manuscript represents a pilot study assessing the feasibility of a single-compartment, individualised, pharmacokinetic algorithm for protamine dosing after cardiopulmonary bypass. A pilot cohort study in a specialist NHS cardiothoracic hospital targeting patients undergoing elective cardiac surgery using cardiopulmonary bypass. Patients received protamine doses according to a pharmacokinetic algorithm (n = 30) or using an empirical, fixed-dose model (n = 30). Categorical differences between the groups were evaluated using the Chi-squared test or Fisher's exact test. Continuous data was analysed using a paired Student's t-test for parametric data and the paired samples Wilcoxon test for non-parametric data. Patients who had protamine dosing according to the algorithm demonstrated a lower protamine requirement post-bypass relative to empirical management as measured by absolute dose (243 ± 49mg vs. 305 ± 34.7mg; p<0.001) and the heparin to protamine ratio (0.79 ± 0.12 vs. 1.1 ± 0.15; p<0.001). There was no difference in the pre- to post-bypass activated clotting time (ACT) ratio (1.05 ± 0.12 vs. 1.02 ± 0.15; p=0.9). Patients who received protamine according to the algorithm had no significant difference in transfusion requirement (13.3% vs. 30.0%; p=0.21). This study showed that an individualized pharmacokinetic algorithm for the reversal of heparin after cardiopulmonary bypass is feasible in comparison with a fixed dosing strategy and may reduce the protamine requirement following on-pump cardiac surgery.

Effects of Hypotensive Anesthesia on Blood Transfusion Rates in Craniosynostosis Corrections

Hypotensive anesthesia is routinely used during craniosynostosis corrections to reduce blood loss. Noting that cerebral oxygenation levels often fell below recommended levels, the authors sought to measure the effects of hypotensive versus standard anesthesia on blood transfusion rates. One hundred children undergoing craniosynostosis corrections were randomized prospectively into two groups: a target mean arterial pressure of either 50 mm Hg or 60 mm Hg. Aside from anesthesiologists, caregivers were blinded and strict transfusion criteria were followed. Multiple variables were analyzed, and appropriate statistical testing was performed. The hypotensive and standard groups appeared similar, with no statistically significant differences in mean age (46.5 months versus 46.5 months), weight (19.25 kg versus 19.49 kg), procedure [anterior remodeling (34 versus 31) versus posterior (19 versus 16)], or preoperative hemoglobin level (13 g/dl versus 12.9 g/dl). Intraoperative mean arterial pressures differed significantly (56 mm Hg versus 66 mm Hg; p < 0.001). The captured cell saver amount was lower in the hypotensive group (163 cc versus 204 cc; p = 0.02), yet no significant differences were noted in postoperative hemoglobin levels (8.8 g/dl versus 9.3 g/dl). Fifteen of 100 patients (15 percent) received allogenic transfusions, but no statistically significant differences were noted in transfusion rates between the hypotensive [nine of 53 (17.0 percent)] and standard anesthesia [six of 47 (13 percent)] group (p = 0.056). No significant difference in transfusion requirements was found between hypotensive and standard anesthesia during craniosynostosis corrections. Considering potential benefits of improved cerebral blood flow and total body perfusion, surgeons might consider performing craniosynostosis corrections without hypotension. Therapeutic, II.

Impact of transjugular intrahepatic portosystemic shunting on liver transplantation: 12-year single-center experience

The purpose of this study was to assess the impact of transjugular intrahepatic portosystemic shunting (TIPS) on liver transplantation (LT). Seventy-two patients transplanted after TIPS insertion between 1996 and 2008 were compared with 136 matched patients transplanted without prior TIPS. At time of LT, 10% of the TIPS were occluded and 32% were misplaced. Shunt removal was difficult in 17% of the TIPS patients and required vena cava clamping in 10%. Collateral venous circulation was less extensive and intra-operative portocaval anastomosis was required more frequently in the TIPS group. No significant difference in transfusion requirements and operative times were observed between the two groups. Postoperatively, liver and renal function tests, in-hospital stay, graft rejection, re-transplantation and 1-year mortality rates were not statistically different. Ascites volume in the first week was greater in the TIPS group (7.6 L vs 6.9 L, P=0.036). In the TIPS group, ascites and collateral circulation were greater if the shunt was occluded at the time of LT. Shunt misplacement or occlusion was not associated with higher intra-operative or postoperative complication rates. TIPS did not impair LT and can provide a safe bridge for LT in the end-stage cirrhotic patients.

Coronary Artery Stents and Antiplatelet Therapy in Patients With Cirrhosis

To describe our experience with coronary artery stenting and antiplatelet therapy in cirrhotic patients and compare rates of bleeding with a control group. Although there are data on cardiac evaluation and perioperative cardiac risk in cirrhotic patients, there is a paucity of information on outcomes in cirrhotic patients with coronary artery stents. Cirrhotic patients may be at increased risk for complications, including gastrointestinal bleeding as a result of antiplatelet therapy prescribed after stenting. We performed a retrospective study of complications in cirrhotics that received a coronary artery stent followed by clopidogrel and aspirin prescribed to prevent stent occlusion. Cirrhotics with stents were compared with an age and sex-matched control group with cirrhosis without stents and not on aspirin. Among 423 cirrhotic patients who underwent liver transplant evaluation, 16 patients (3.8%) received a stent of which 9 underwent liver transplant. Two patients with varices (12.5%) in the stent group had fatal variceal bleeding and 2 controls (6.3%) had nonfatal variceal bleeding during follow-up while on antiplatelet therapy (P=0.86). There were no significant differences in transfusion requirements between the 9 liver transplant recipients with stents compared with the control group, P=0.69 for packed red blood cells. In our experience, it is safe for cirrhotic patients without varices to receive a coronary artery stent and for cirrhotic patients with coronary artery stents to be considered for liver transplantation. Larger prospective studies are needed to confirm these results and evaluate the risk of bleeding in cirrhotics with varices who receive coronary artery stents and antiplatelet therapy.

Splenic salvage using an absorbable mesh: feasibility, reliability and safety.

Forty-nine adults underwent surgery for splenic injury: 17 (group 1) had salvage with a splenic mesh, seven (group 2) underwent other preservation techniques, and 25 (group 3) underwent splenectomy. There were six, zero and 11 hilar lesions in groups 1, 2 and 3, respectively. Seven of 15 associated lesions involved the digestive tract. There was no significant difference in transfusion requirements, length of operation or postoperative complications. One patient died in each of groups 1 and 2, and eight in group 3. Secondary splenectomy was performed once in groups 1 and 2. The duration of hospital stay was shorter in the preservation groups (1 and 2) than in group 3. Splenic preservation was feasible in 24 of 49 adults with splenic injury requiring surgery. The splenic mesh wrap is safe and reliable, and allows splenic salvage even with hilar injury.

Learning curve of laparoscopy-assisted distal gastrectomy with systemic lymphadenectomy for early gastric cancer

To evaluate the nature of the "learning curve" for laparoscopy-assisted distal gastrectomy (LADG) with systemic lymphadenectomy for early gastric cancer. The data of 90 consecutive patients with early gastric cancer who underwent LADG with systemic lymphadenectomy between April 2003 and November 2004 were reviewed. The 90 patients were divided into 9 sequential groups of 10 cases in each group and the average operative time of these 9 groups were determined. Other learning indicators, such as transfusion requirements, conversion rates to open surgery, postoperative complication, time to first flatus, and postoperative hospital stay, were evaluated. After the first 10 LADGs, the operative time reached its first plateau (230-240 min/operation) and then reached a second plateau (<200 min/operation) for the final 30 cases. Although a significant improvement in the operative time was noted after the first 50 cases, there were no significant differences in transfusion requirements, conversion rates to open surgery, postoperative complications, time to first flatus, or postoperative hospital stay between the groups. Based on operative time analysis, this study show that experience of 50 cases of LADG with systemic lymphadenectomy for early gastric cancer is required to achieve optimum proficiency.

Outpatient Supportive Care Following Chemotherapy for Acute Myeloblastic Leukemia

Treatment of acute myeloid leukemia (AML) involves aggressive myelosuppressive chemotherapy that is generally administered on an inpatient basis. In our centre, AML therapy has been initiated in hospital and followed by early outpatient supportive care according to guidelines established in 1996. We conducted a review of all patients presenting with AML in our centre between January 1996 and July 1998 to evaluate the safety and feasibility of early outpatient supportive care. Nineteen consecutive patients treated with induction chemotherapy were analyzed. Patients were treated with cytosine arabinoside and an anthracycline as aggressive AML induction therapy with the intent for early discharge. Ten patients (53%) were discharged within 10 days of starting induction chemotherapy (median 4.5 days). Reasons for remaining in hospital included sepsis, serious medical complications, and social and geographic factors. Patients discharged early had a median of 1.5 readmissions (range 0–3), but had 30% fewer in-hospital days man inpatients (p=0.03), and 57% fewer days of in-hospital antibiotic therapy (p=0.01). There were no significant differences in transfusion requirements or episodes of febrile neutropenia between the two groups. Thirty-one cycles of consolidation therapy were administered to the 18 patients who survived induction. Early discharge from hospital was achieved for 30 cycles (97%). Nine cycles of consolidation chemotherapy were delivered using outpatient intravenous infusion pumps (29%). This study supports the feasibility and safety of early discharge and outpatient supportive care following chemotherapy for AML.

Effect of Recombinant Human Erythropoietin on Transfusion Risk in Coronary Bypass Patients

Background. Patients having a cardiac operation frequently require allogeneic blood transfusions despite surgical blood-conservation techniques. Recombinant human erythropoietin (Epoetin alfa) may augment this conservation by stimulating erythropoiesis. The safety and efficacy of perioperative use of Epoetin alfa to reduce the need of allogeneic transfusion was studied. Methods. A multicenter double-blind, placebo-controlled, parallel-group study involved 182 patients having coronary artery bypass grafting and randomized to receive Epoetin alfa (300 or 150 IU/kg) or placebo subcutaneously for 5 days before, on the day of, and for 2 days after operation. Results. Perioperative Epoetin alfa resulted in greater increases in baseline to preoperative hemoglobin levels and hematocrit (300 IU/kg) and in presurgery to postsurgical day 1 reticulocyte counts versus placebo ( p ≤ 0.05). However, there was no significant difference in transfusion requirements. Incidences of adverse events were similar in all study groups. Conclusions. Lower incidences of allogeneic blood exposure were observed in both Epoetin alfa–treated groups; however, the differences between all treatment groups were not significant. This was probably due to the relatively short 5-day preoperative course of Epoetin alfa therapy. There were no significant differences between the three groups relative to safety. Epoetin alfa was well tolerated in this population.

Prospective randomized evaluation of blood salvage techniques for primary total hip arthroplasty

A controlled, randomized, prospective study was performed evaluating the need for perioperative blood salvage for primary total hip arthroplasty patients who had donated autologous blood before surgery. One hundred fifty-three patients able to donate at least 2 units of autologous blood were divided into four groups. In group 1 (35 patients), intraoperative and postoperative Cell-Saver (Haemonetics, Braintree, MA) was employed. In group 2 (40 patients), a postoperative Solcotrans (Smith & Nephew Richards, Memphis, TN) reinfusion protocol was followed. In group 3 (40 patients), a closed-suction Hemovac drain (Zimmer, Warsaw, IN) was placed. In group 4, (38 patients), no drain was used. Decisions for transfusion were based on clinical and laboratory parameters and made in conjunction with medical consultation. All autologous blood was routinely reinfused. There was no statistically significant difference in transfusion requirements or wound complications among the four groups. Hemoglobin and hematocrit changes between groups also were not statistically significant, but a power test suggested insufficient patient numbers for absolute reliability of this observation. Only five patients (3.3%) in this study received homologous blood. Four of these patients were in the Solcotrans group and one was in the Cell-Saver group. Two reoperations were performed: one for hematoma (Solcotrans group) and one for a sewn-in drain. It is concluded that expensive perioperative blood salvage techniques are usually not needed in patients who have a primary total hip arthroplasty without cement and who have donated 2 units of blood before operation.