Total Estimated Blood Loss Research Articles

Lymphadenectomy along the left recurrent laryngeal nerve by a minimally invasive esophagectomy in the prone position for thoracic esophageal cancer

A thoracoabdominal esophagectomy for esophageal cancer is a severely invasive procedure. A thoracoscopic esophagectomy may minimize injury to the chest wall and reduce surgical invasiveness. Conventional thoracoscopic procedures are performed in the left lateral-decubitus position. Recently, procedures performed in the prone position have received more attention because of improvements in operative exposure or surgeon ergonomics. However, the efficacy of the prone position in an aggressive thoracoscopic esophagectomy with an extensive lymphadenectomy has not been fully documented. We successfully performed a thoracoscopic esophagectomy with a three-field extensive lymphadenectomy in 43 esophageal carcinoma patients in the prone position from December 2007 to December 2009. We describe our procedures with the patients in the prone position, focusing especially on a lymphadenectomy along the left recurrent laryngeal nerve where the nodes are frequently involved and precise dissection is technically challenging. To determine further the advantages of this position, we retrospectively compared surgical outcomes in 43 patients to those of 34 patients who underwent a thoracoscopic esophagectomy in the left lateral decubitus position as a historical control from January 2006 to November 2007. It was easier to explore the operative field around the left recurrent laryngeal nerve during a thoracoscopic esophagectomy in the prone position. The mean duration of the aggressive thoracoscopic procedure in the prone position was 307 min, which was significantly longer than in the left lateral decubitus position, but the total estimated blood loss in the prone position was significantly lower. There was no difference in the incidence of postoperative complications between the two procedures. A thoracoscopic esophagectomy in the prone position is technically safe and feasible and provides better surgeon ergonomics and better operative exposure around the left recurrent laryngeal nerve during an aggressive esophagectomy.

Simultaneous Resection of Colorectal Cancer and Synchronous Liver Metastases: Initial Experience of Laparoscopy for Colorectal Cancer Resection

Background/Aims:Although laparoscopy is accepted for treatment of colorectal cancer, there is no established consensus for its use when resection of synchronous liver metastases is performed simultaneously. The purpose of this study was to evaluate whether laparoscopic colorectal resection with simultaneous resection of synchronous liver metastases was technically feasible and whether it may be a therapeutic option. Methods: Ten patients underwent laparoscopic resection for primary colorectal cancer, combined with synchronous resection of liver metastases. Results: The primary tumor location was in the sigmoid colon in 3 patients and the rectum in 7. All laparoscopic colorectal resections were successful, with no conversion to open surgery. Simultaneously, there were 7 conventional open and 3 laparoscopy-assisted liver resections. The median total operating time was 446 (range 300–745) min, including 222 (range 152–313) min for colorectal resection. The median total estimated blood loss was 175 (range 30–1,200) ml, including 10 (range 0–550) ml for colorectal resection. There was no major morbidity, except 1 patient who developed decubitus. Conclusion: This preliminary report suggests that laparoscopic resection for sigmoid colon and rectal cancer, combined with synchronous resection of liver metastases, is a safe and feasible procedure in selected patients.

Can Posterior-Only Surgery Provide Similar Radiographic and Clinical Results as Combined Anterior (Thoracotomy/Thoracoabdominal)/Posterior Approaches for Adult Scoliosis?

Retrospective matched cohort analysis. To determine if posterior-only (post-only) surgical techniques consisting of pedicle screws, osteotomies, transforaminal lumbar interbody fusion, and bone morphogenetic protein-2 may provide similar results as compared anterior (thoracotomy/thoracoabdominal)/posterior surgical approaches for the treatment of adult spinal deformity with respect to correction, fusion rates, or outcomes. Combined anterior/posterior (A/P) fusion has traditionally been used to treat many adult scoliosis deformities. Anterior approaches negatively impact pulmonary function and require additional operative time and anesthesia. Twenty-four patients who had A/P fusion for primary adult scoliosis (16 staged, 8 same-day) were matched with a cohort of 24 patients who had post-only treatment. Anterior fusion was performed via a thoracotomy (n = 1)/thoracoabdominal (n = 23) approach. All post-only surgeries were under one anesthesia. Minimum 2-year follow-up included radiographic, clinical, and outcomes data. There were no significant differences between groups for age, gender, diagnosis, comorbidities, preoperative curve magnitudes, or global balance. Postoperative radiographic correction and alignment were similar for both groups except for thoracolumbar curve percent improvement which was statistically better in the post-only group (P = 0.03). The average surgical time was higher in A/P versus post-only group (11.6 vs. 6.9 hours, P < 0.0001) as was total estimated blood loss (1330 vs. 980 mL, P = 0.04). Hospital length of stay (LOS) was longer in A/P versus post-only group (11.9 vs. 8.3 days, P = 0.03). There were no significant differences between postoperative complications. Revision surgery was performed in 5 A/P and 2 post-only patients. Higher pseudarthrosis rates found in the A/P versus post-only (17 vs. 0%) were not significant (P = 0.11). SRS-30 and Oswestry scores reflected a similar patient assessment before surgery, and improvement between groups at follow-up. Post-only adult scoliosis surgery achieved similar correction to A/P surgery while decreasing blood loss, operative time, length of stay, and avoiding additional anesthesia. Complications, radiographic, and clinical outcomes were similar at over 2-year follow-up.

Effect of Coblation Polypectomy on Estimated Blood Loss in Endoscopic Sinus Surgery

We conducted a pilot study comparing estimated blood loss (EBL) using coblation-assisted endoscopic sinus surgery (CAESS) where coblation is used to debulk nasal polyps before microdebridement with a traditional microdebrider technique in chronic rhinosinusitis (CRS) patients with sinonasal polyps undergoing endoscopic sinus surgery (ESS). A retrospective analysis was performed at a tertiary care center on patients with nasal polyposis undergoing ESS between January 2008 and July 2008. The University of Miami CT staging system was used preoperatively to evaluate the extent of sinonasal disease. The duration of surgery, blood loss per minute, total EBL, and demographic data were collected. Twenty-one patients underwent nasal polypectomy/ESS using CAESS and 16 patients underwent nasal polypectomy/ESS using microdebridement. The two groups had comparable University of Miami CT staging scores (p>0.05). The average EBL was 307.1+/-169.8 mL using coblation compared with 627.8+/-424.2 mL using microdebridement (p<0.05). The average duration of surgery using coblation was 116.2+/-41.7 minutes, compared with 125.3+/-48.4 minutes using microdebridement (p>0.05). The average blood loss per minute was 2.8+/-1.7 mL in the coblation group compared with 4.8+/-2.1 mL in the microdebridement group (p<0.05). Subgroup analyses showed a significant decrease in average EBL and EBL/minute to be only significant for revision cases (p<0.05) and not for primary cases (p>0.05). Coblation-assisted nasal polypectomy/ESS is associated with a statistically significant lower EBL and blood loss per minute when compared with traditional microdebridement technique. Coblation represents a new device that can reduce blood loss in patients with nasal polyposis undergoing traditional revision ESS. Further prospective randomized trials are needed to validate these findings.

Effect of Intraoperative Injection of 0.25% Bupivacaine with 1:200,000 Epinephrine on Intraoperative Blood Loss in FESS

This study was designed to compare differences in intraoperative blood loss, mean arterial blood pressure (MABP), and duration of surgery when 0.25% bupivacaine with 1:200000 epinephrine is injected, preoperatively, versus normal saline (NS), during functional endoscopic sinus surgery (FESS). A prospective, double-blind randomized placebo-controlled study was performed. Part I involved 46 patients who were infiltrated with 0.25% bupivacaine with 1:200000 epinephrine on one side of the nose and sterile NS on the other (control). Part II involved 30 patients infiltrated with 0.25% bupivacaine with 1:200000 epinephrine bilaterally and 30 patients with NS bilaterally (control). Patient demographics, preoperative MABP, intraoperative MABP, duration of surgery, and total estimated blood loss (EBL) were recorded for each side (Part I) and case (Part II). For part I, there were 46 patients (mean age, 49 years), 24 women and 22 men. MABP was 72 mmHg for each side (p = 0.97). Preoperative MABP was 93 mmHg. Duration of surgery was 48 minutes for epinephrine side and 45 minutes for control (p = 0.17). Total EBL was 185 mL for the epinephrine side and 197 mL for control (p = 0.53). For Part II, there were 60 patients (mean age, 56 years), 28 women and 32 men. The MABP was 77 mmHg for the epinephrine group and 72 mmHg for control (p = 0.048). Preoperative MABP was 100 mmHg for the epinephrine group and 97 mmHg for control (p = 0.37). Duration of surgery was 2.25 hours for the epinephrine group and 2.08 hours for control (p = 0.17). Total EBL was 589 mL for the epinephrine group and 538 mL for control (p = 0.64). There was no significant reduction in intraoperative blood loss during FESS when local anesthetic containing epinephrine was used compared with infiltration with NS. More importantly, Part II shows a significantly higher MABP associated with infiltration of epinephrine. Parts I and II did not show a significant difference in preoperative MABP or duration of surgery.

Utility of the Gyrus open forceps in hepatic parenchymal transection

ObjectiveThis study aimed to evaluate if the Gyrus open forceps is a safe and efficient tool for hepatic parenchymal transection. BackgroundBlood loss during hepatic transection remains a significant risk factor for morbidity and mortality associated with liver surgery. Various electrosurgical devices have been engineered to reduce blood loss. The Gyrus open forceps is a bipolar cautery device which has recently been introduced into hepatic surgery. MethodsWe conducted a single-institution, retrospective review of all liver resections performed from November 2005 through November 2007. Patients undergoing resection of at least two liver segments where the Gyrus was the primary method of transection were included. Patient charts were reviewed; clinicopathological data were collected. ResultsOf the 215 open liver resections performed during the study period, 47 patients met the inclusion criteria. Mean patient age was 61 years; 34% were female. The majority required resection for malignant disease (94%); frequent indications included colorectal metastasis (66%), hepatocellular carcinoma (6%) and cholangiocarcinoma (4%). Right hemihepatectomy (49%), left hemihepatectomy (13%) and right trisectionectomy (13%) were the most frequently performed procedures. A total of 26 patients (55%) underwent a major ancillary procedure concurrently. There were no operative mortalities. Median operative time was 220min (range 97–398min). Inflow occlusion was required in nine patients (19%) for a median time of 12min (range 3–30min). Median total estimated blood loss was 400ml (range 10–2000ml) and 10 patients (21%) required perioperative transfusion. All patients had macroscopically negative margins. Median length of stay was 8 days. Two patients (4%) had clinically significant bile leak. The 30-day postoperative mortality was zero. ConclusionsUse of the Gyrus open forceps appears to be a safe and efficient manner of hepatic parenchymal transection which allows rapid transection with acceptable blood loss, a low rate of perioperative transfusion, and minimal postoperative bile leak.

Use of Intra-Arterial Chemotherapy and Embolization Before Limb Salvage Surgery for Osteosarcoma of the Lower Extremity

We report our experience with the use of intra-arterial chemotherapy and embolization before limb salvage surgery in patients with osteosarcoma of the lower extremity. We evaluated the effect of this procedure on the degree of tumor necrosis and on the amount of blood loss during surgery. We reviewed the medical records of all patients who received intra-arterial chemotherapy and embolization before undergoing limb salvage surgery for osteosarcoma of the lower extremity at our institution between January 2003 and April 2008. Patient demographic, tumor characteristics, treatment details, postembolization complications, and surgical and pathological findings were recorded for each patient. We evaluated the operative time, estimated blood loss (EBL), and volume of blood transfusion during surgery and in the postoperative period in all patients in the study group. The same parameters were recorded for 65 other patients with lower extremity osteosarcoma who underwent limb salvage operation at our institution without undergoing preoperative intervention. The study included 47 patients (25 males and 22 females). Angiography showed that the tumors were hypervascular. Intra-arterial chemotherapy and embolization were performed successfully, resulting in a substantial reduction or complete disappearance of tumor stain in all patients. No major complications were encountered. At the time of surgery, performed 3-7 days after embolization, a fibrous edematous band around the tumor was observed in 43 of the 47 patients, facilitating surgery. The goal of limb salvage was achieved successfully in all cases. Percentage tumor necrosis induced by treatment ranged from 70.2% to 94.2% (average, 82.9%). EBL during surgery, EBL from drains in the postoperative period, total EBL, and transfusion volumes were significantly lower in the 47 study patients compared to the 65 patients who underwent surgery without preoperative treatment with intra-arterial chemotherapy and embolization. The mean operative time was also significantly less in the intervention group compared to the nonintervention group (73.2 vs. 88.5 min; p < 0.05). In conclusion, intra-arterial chemotherapy and embolization performed 3 to 7 days before limb salvage surgery in patients with lower extremity osteosarcomas can cause substantial tumor necrosis, reduce the EBL and transfusion requirements during surgery, and induce formation of a false capsule around the tumor, thus facilitating surgical excision of the tumors.

Learning Curve with Robotic-Assisted Laparoscopic Radical Prostatectomy: A Prospective Study

Purpose: To investigate the learning curve and its characteristics in our initial experiences with robotic-assisted laparoscopic radical prostatectomy (RLRP) with a new da Vinci-S surgical system. Materials and Methods: Through inspection of the patients who underwent RLRP by a single urologic surgeon from July 2007 to May 2008, the variables related to surgery were evaluated prospectively. Results: RLRP was performed in 50 patients. The patients’ mean age (range) was 63 years (50-73 years), and 11 patients had a history of previous abdominal surgery. The mean total operation time was 281.6 min (190-455 min). The mean set-up time was 18.6 min (14-30 min), and the mean console time was 219.8 min (150-400 min). The mean estimated blood loss (EBL) was 375.7ml (200-800 ml). The overall margin-positive rate was 26% (13/50); it was 11.9% (5/42) for pT2 tumors and 100% (8/8) for pT3 tumors. Minor complications occurred in 5 patients. All complications were treated effectively with only conservative management. The total operation time, set-up time, console time, and EBL significantly decreased as the number of patients treated grew (Spearman’s rank correlation, p<0.05; Rho=−0.49, −0.35, −0.54, −0.75, respectively). The mean total operation time, set-up time, console time, and EBL were significantly decreased in the last 35 patients who needed no transfusion (p<0.05). Conclusions: The use of robotic surgery allowed the surgeon to complete the learning curve in a relatively short time period, with low perioperative complication rates and potentially good oncologic results, as indicated by the acceptable positive surgical margin in the patients with pathologically organ-confined disease. (Korean J Urol 2009;50:140-147) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section—Pilot study. ISRCTN 40302163

Objective To compare the blood loss at elective lower segment caesarean section with administration of oxytocin 5IU bolus versus oxytocin 5IU bolus and oxytocin 30IU infusion and to establish whether a large multi-centre trial is feasible. Study design Women booked for an elective caesarean section were recruited to a pilot randomised controlled trial and randomised to either oxytocin 5IU bolus and placebo infusion or oxytocin 5IU bolus and oxytocin 30IU infusion. We wished to establish whether the study design was feasible and acceptable and to establish sample size estimates for a definitive multi-centre trial. The outcome measures were total estimated blood loss at caesarean section and in the immediate postpartum period and the need for an additional uterotonic agent. Results A total of 115 women were randomised and 110 were suitable for analysis (5 protocol violations). Despite strict exclusion criteria 84% of the target population were considered eligible for study participation and of those approached only 15% declined to participate and 11% delivered prior to the planned date. The total mean estimated blood loss was lower in the oxytocin infusion arm compared to placebo (567 ml versus 624 ml) and fewer women had a major haemorrhage (>1000 ml, 14% versus 17%) or required an additional uterotonic agent (5% versus 11%). A sample size of 1500 in each arm would be required to demonstrate a 3% absolute reduction in major haemorrhage (from baseline 10%) with >80% power. Conclusion An additional oxytocin infusion at elective caesarean section may reduce blood loss and warrants evaluation in a large multi-centre trial.

Influence of prostate weight, obesity and height on surgical outcomes of robot-assisted laparoscopic radical prostatectomy in Korean men.

The purpose of this study was to determine if different body habitus, including prostate weight, body mass index (BMI) and height, are associated with surgical outcomes in patients undergoing robot-assisted laparoscopic radical prostatectomy (RLRP). Between July 2005 and June 2007, 135 patients underwent RLRP by a single surgeon. Information was collected retrospectively on prostate weight, BMI and height. Surgical outcome was assessed by total operative time, estimated blood loss (EBL) and surgical margin as parameters of technical difficulty. When statistically analyzed, prostate size was significantly related to total operative time (P = 0.001) and EBL (P = 0.033). But prostate size was not significantly related to the surgical margin. Patient BMI and height did not appear to affect surgical outcomes. Despite a shift in body frames towards the western standard, most Asians still have shorter stature, lower BMI and smaller prostates. We have found from our experience that different body habitus is not significantly related to surgical outcomes of RLRP, and therefore, it seems promising to operate successfully on Asian patients. However, it is important to obtain long-term outcomes on a larger cohort of patients in order to confirm our findings.

P27.13: Changing of kidney volume in pregnancy‐associated hypertension and/or proteinuria (3D study)

because of contractions was performed at 32/6 weeks of gestation. A viable 1840 g female infant with Apgar scores of 8, 8 and 9 and umbilical artery pH 7.32 was delivered. At the time of delivery, approximately 600 mL of fresh blood gushed from the uterine incision before amniotomy. The total estimated blood loss from the surgery was 500 mL. The mother had an unremarkable postoperative course and was discharged in stable condition on postpartum day 8. The neoanate was admitted to the neonatal intensive care unit for prematurity and respiratory distress syndrome.

Perioperative complications in a patient with sickle cell disease following penetrating trauma

A 26-year-old male with documented SCD (Hgb SS)presentedtotheEmergencyDepartmentwithmulti-ple gun shot wounds. The patient had bullet woundsintheleftlowerquadrantandtheleftflankaswellastwo wounds to the left upper extremity (with anobvious deformity) and a single wound to the rightlower extremity (with the bullet palpable in thesubcutaneous tissue). The patient was in distress,tachycardic, diaphoretic with a rigid abdomen. Achest roentegram was reported as being normal,followingwhich,anexploratorylaparotomywasper-formed. Findings at laparotomy were four perforat-ing small bowel injuries with a small serosal tear inthe left colon. A small bowel resection (including allfour injuries and comprising of 50 cm of proximalileum)withprimaryanastomosiswasperformed.Thecolonic serosal injury was also oversewn. Total esti-mated blood loss was 300 cm

44. Phase I Study of Ad5-TRAIL in Men with Clinically Organ Confined Prostate Cancer

AACR Annual Meeting-- Apr 14-18, 2007; Los Angeles, CA 4870 We have developed a recombinant adenovirus that encodes human TNF-related apoptosis-inducing ligand (TRAIL; Ad5-TRAIL), which is a potent inducer of tumor cell apoptosis but is not cytotoxic to normal cells. In vitro infection of human prostate tumor cells with Ad5-TRAIL resulted in the rapid transcription and translation of the transferred TRAIL gene into functional TRAIL protein that, when expressed on the cell surface, induced apoptotic death in TRAIL-sensitive prostate tumor cell targets but not normal prostate epithelial cells. Furthermore, in vivo preclinical studies have revealed Ad5-TRAIL can inhibit or slow the outgrowth of human prostate tumor xenografts in SCID mice. Thus, the primary objective of the study is to determine the local and systemic toxicity associated with intraprostatic injection of Ad5-TRAIL delivered in a collagen matrix in men with locally confined prostate cancer, and determine the maximum tolerated dose from four different dose levels. Secondary study objectives will examine the distribution of Ad5-TRAIL within the human prostate after transrectal injection, to determine the effect of transrectal injection of Ad5-TRAIL on existent prostate cancer, and to determine the effect of Ad5-TRAIL-induced apoptosis on immune activation to prostate antigens. Prostate cancer patients (T1c, T2a, T2b and N0, M0) scheduled to undergo radical prostatectomy (RRP) within 10 d following study entry were chosen. The patients had 4 intraprostatic injections of Ad5-TRAIL, 2 per prostate lobe. One week later, endorectal MRI was performed prior to RRP to rule out abscess. Laboratory assessment was performed to assess systemic infection. RRP was then performed if there was no adverse reaction. Operation difficulty was compared to non-injected control patients. Standard histologic evaluation and Gleason grading was performed. Evaluation of the inflammatory infiltrates in Ad5-TRAIL-treated prostates was assessed and compared to control prostate biopsies. To date (11/06), three patients have received the initial vector concentration. There were no immediate or delayed allergic reactions. None of the patients showed abscess on MRI. Operatively, there was no indication of increased inflammation (p=.495), difficulty of the operation, length of stay (p=0.724), or total estimated blood loss. There was no significant increased morbidity post-operatively. All patients had negative margins. Pathologically, each patient had an increase in staging from clinically, and viral vector uptake was shown through visualization of the collagen matrix in the specimen. Ad-5 TRAIL in vivo is known to induce apoptosis in prostate cancer. The initial dose level shows intraprostatic injection is well-tolerated and remains in the prostate after injection. Further increases in dosing will reveal the maximum tolerated dose, and likelihood of increased apoptosis in prostatectomy specimens.

Vertebral artery injury in C-1 lateral mass screw fixation

Atlantal lateral mass screw fixation is an increasingly popular procedure that is viewed as less demanding—and with lower risk of vertebral artery (VA) injury—than atlantoaxial transarticular fixation.2,3,5 We report a case in which the VA was injured during an atlantal lateral mass screw fixation procedure, however, to draw attention to this unusual complication. Of 10 patients in whom this technique was used between 2003 and 2004, we documented one VA injury in a 76-year-old woman who suffered from depression. She sustained a Levine‐Edwards 4 Type II traumatic C-2 spondylolisthesis injury involving a C-3 compression fracture. Initial halo fixation was abandoned because of her mental state. Posterior C1‐3 fusion was planned in light of the patient’s history of pharyngeal cancer and bronchiectasis. Preoperative computed tomography (CT) scanning at C-1 revealed no abnormality (Fig. 1). During surgery, C-1 screw entry points were drilled at the intersection of the inferior border of the posterior arch and the midpoint of the lateral mass 3 without sacrificing the greater occipital nerve. Using lateral fluoroscopy, trajectories were drilled with a 2-mm bit. Unfortunately, when the left screw hole was tapped, the 4-mm tap traversed the superior wall of the posterior arch, damaging the VA (Fig. 2). Although bleeding was stopped by compression, the preoperative plan was abandoned in favor of occipitocervical fixation. The total estimated blood loss was 750 ml. A pseudoaneurysm detected immediately after surgery was evaluated every 4 months and gradually decreased in size (Fig. 3). The postsurgical course has been uneventful, requiring no further treatment, during a 30-month period of observation.

One- or two-stage bilateral total hip arthroplasty

We compared the safety and outcome of one-stage bilateral total hip arthroplasty with those of a two-stage procedure during different admissions in a prospective, randomised controlled trial in an Asian population. Of 168 patients included in the study, 83 had a single- and 85 a two-stage procedure. Most of the patients (59.9%) suffered from inflammatory arthritis. The intra-operative complications, early systemic complications, the operating time, positioning of the components, the functional score, restoration of limb length and survival rates at 96 months were similar in the two groups. The total estimated blood loss was significantly lower in patients undergoing a one-stage procedure than in patients who had a two-stage procedure, but the transfusion requirements were significantly higher in the former group (p=0.001). The hospital stay was significantly shorter in the one-stage group, 7.25 days (sd 1.30; 5 to 20) compared with 10 days (sd 1.65; 8 to 24) in the two-stage group (p=0.023). We believe that a one-stage procedure is safe and appropriate in our population.

Fertility-Sparing Surgery for Ovarian Low Malignant Potential Tumors

Ovarian tumors with low malignancy potential can be treated with simple surgical excision without removing the uterus and remaining ovary. For this study, the outcomes of women with low-malignant-potential (LMP) ovarian tumors who underwent fertility-sparing surgery were compared with those of women who had more extensive surgery. A review of medical charts at the authors' institution from January 1984 to June 2003 identified 249 women with ovarian LMP tumors, 38 (15%) of whom were treated with fertility-sparing surgery. The remaining 211 patients served as controls for this study. Women who had fertility-sparing surgery were a mean age of 26 years compared to 48 years for women who had complete resection and had lower mean gravidity (0.5 vs 2) and parity (0 vs 2) compared with controls (P <.001 for all). More Hispanic and Asian women were younger than age 40 compared with black and white women (P <.01), and they more commonly underwent fertility-sparing surgery (P =.002). Total estimated blood loss was less among patients who were treated with fertility- sparing procedures than controls (125 mL vs 300 mL; P < 0.001), and surgical staging was less common in the women treated with unilateral oophorectomy than in women who had complete resection (65 vs 184; P =.04). Among patients who were staged, those with stage I disease (34 of 196, 17%) were more likely to receive fertility-sparing treatment than stage II or III patients (4 of 53, 8%). Among the 38 patients who had fertility-sparing surgery, 33 underwent unilateral salpingo-oophorectomy. No evidence of disease was seen in 6 women who had concomitant contralateral ovarian cystectomy or in 3 of 4 women who underwent biopsy of the contralateral ovary with no visible indication of disease. The fourth woman was found to have a serous LMP tumor that mirrored the primary tumor. Five women were treated with ovarian cystectomy (5 of 38; 13%). Four were bilateral procedures and one was unilateral. There were 6 recurrences among the 38 patients treated with fertility-sparing surgery, including 5 serous tumors and one mucinous tumor. Five recurrent lesions were in the contralateral ovary. One woman was diagnosed with positive peritoneal cytology for pelvic pain 5 months after ovarian cystectomy for a serous LMP tumor. She had no other treatment and has not recurred. The remaining 4 patients were disease-free for 62, 122, 117, and 18 months from initial treatment. These 4 patients were treated with surgery alone and all are alive and well.

Variables influençant le saignement lors d’une arthroplastie totale de hanche

Purpose of the study The purpose of this retrospective analysis was to study the parameters having an effect on blood loss during or after total hip arthroplasty. We examined a series of 350 procedures for primary degenerative hip disease with a normal course (n = 100), rapidly destructive degenerative disease (n = 100), and secondary joint degeneration due to atraumatic osteonecrosis of the femoral head (n = 100) or rheumatoid disease (n = 50). Material and methods All arthroplasties were performed via the transtrochanteric approach using Charnley-Kerboull implants. The volume of blood loss was calculated by noting compensated blood loss (transfusion during the procedure and shortly thereafter), and estimated non-compensated loss using the Nadler and Mercuriali and Inghilleri formula. We examined the influence of age, gender, obesity, and surgeon experience. Data were analyzed with the Student-Fisher reduced deviation method was used for quantitative and qualitative variables and the coefficient of correlation for quantitative variables. Results Blood loss, calculated in ml packed red blood cells (hematocrit 100%), was 573 ml for arthroplasties with a normal course, 713 for arthroplasties secondary to osteonecrosis of the femoral head, and 950 ml for rapidly destructive degenerative disease and finally 609 ml for patients with rheumatoid arthritis. Considering 35% as normal for hematocrit, total estimated blood loss was 1 640, 2 040, 2 710, and 1 740 ml respectively in the different groups. Compared with the group of patients who had a normal course, total blood loss was significantly higher when arthroplasty was performed for osteonecrosis and rapidly destructive degenerative disease (p < 0.001). Age, obesity, and duration of the intervention had no effect on blood loss. Female gender and operator experience had a favorable influence in the group of patients who underwent hip surgery for primary degenerative disease. Blood loss occurring during or shortly after total hip arthroplasty was greater in men, when the procedure was performed for osteonecrosis, and most importantly for rapidly destructive diseases. Discussion In clinical practice, the influence of gender is not significant enough to require specific preoperative transfusion plans. Conversely, certain etiologies of the joint disease impose transfusion in all such patients, using a blood volume which usually exceeds the possibilities of auto-transfusions.

Analysis of a Critical Pathway in Osteoplastic Flap for Frontal Sinus Obliteration

A critical pathway was applied to patients undergoing osteoplastic flap (OPF) for frontal sinus obliteration to determine whether efficiency could be improved. A retrospective review of consecutive OPF procedures (n = 51) performed between 1992 and July 1997 was conducted. The patient groups were subdivided into those who underwent OPF alone and those who had endoscopic sinus procedures performed in addition to OPF. Comparisons were made between the precritical pathway and post-critical pathway groups, specifically noting operative time, total operating room (OR) time, estimated blood loss (EBL), length of hospital stay, and costs. We used a critical pathway that was developed for endoscopic sinus procedures at our institution through a multidisciplinary team approach. Preoperative evaluation and testing, intraoperative equipment and medications, and postoperative care including follow-up clinic visits were all standardized. An unpaired, two-tailed Student t test was used to evaluate the data. Statistically significant (P<.05) reductions in operative times, total OR time, EBL, and length of hospital stay were observed in the post-critical pathway group who underwent endoscopic sinus procedures as well as OPF. Costs to the OR were reduced 29% and 15% for OPF and for OPF with endoscopic surgery, respectively. Patient costs were reduced 5% and 4% in these groups, respectively. With implementation of effective critical pathways, significant decreases in length of stay are seen, and cost reductions can be realized through the improved efficiency, shortened OR times, and decreases in redundancy of ordering materials.

Ischemic optic neuropathy after hemorrhage from a cornual ectopic gestation

A case of ischemic optic neuropathy resulting from uterine hemorrhage is reported in which a 37-year-old white woman, gravida 1, para 0, was diagnosed at 8 weeks' gestation with a ruptured ectopic pregnancy. After diagnostic laparoscopy the patient underwent a minilaparotomy, cornual wedge resection, and right salpingectomy with a total estimated blood loss of 3000 ml. Her postoperative course was uneventful until postoperative day 4, when the patient complained of vision loss for the last 1 to 2 days, total body edema, and headache. Ophthalmologic examination revealed findings consistent with ischemic optic neuropathy. Multiple studies of the cerebrospinal fluid were negative, as were computed tomography studies and magnetic resonance imaging of the head. Ischemic optic neuropathy, whose pathogenesis is still unclear, is a rare complication of massive hemorrhage and may cause permanent vision loss.(Am J Obstet Gynecol 1997;177:1550-2.)

Estimated Blood Loss and Transfusion Rates Associated with Percutaneous Nephrolithotomy

We analyzed retrospectively 127 percutaneous nephrolithotomies performed on 96 patients between 1986 and 1989 to estimate the average total blood loss from the procedure. Blood transfusions and a postoperative decrease in hemoglobin level were combined to estimate total blood loss. The average blood loss for uncomplicated 1-stage single puncture percutaneous nephrolithotomy was 2.8gm./dl. hemoglobin. Factors potentially influencing blood loss were identified. Multiple punctures and/or renal pelvic perforation was associated with a 2-fold greater blood loss. Half of the expected blood loss occurred in patients with a preexisting nephrostomy tract. Calculus morphology, location, composition and length did not affect total blood loss, nor did the number of fragments or stone-containing calices. Other factors, such as puncture site, type of fascial dilation, hypertension, renal insufficiency, infection, previous open renal surgery or previous extracorporeal shock wave lithotripsy, also did not affect total estimated blood loss. During the study years the blood transfusion rate was 23% in all patients and 14% in those with a single puncture uncomplicated by renal pelvic perforation and without a mature nephrostomy tract. The only statistically significant risk factors influencing the likelihood of a blood transfusion were preoperative anemia and total blood loss. Although our current transfusion rate associated with percutaneous nephrolithotomy (4% in nonanemic patients from 1989 to 1992) is much lower, patients must be made aware of the likelihood of blood transfusion, and urologists should recognize the risk factors for blood loss and transfusion.