Epidural analgesia in hepatic resection

BACKGROUND: Randomized trials show equivocal benefit of epidural analgesia (EA) for patients undergoing abdominal operations. Partial hepatectomy is often performed using low central venous pressure anesthesia to reduce intraoperative blood loss. We examined effects of pain management strategy on blood pressure, transfusion, and complications in patients undergoing hepatic resection with either EA or IV analgesia (IVA). STUDY DESIGN: Data on patients undergoing hepatectomy from 2001 to 2004 at Emory University Hospital were analyzed according to route of perioperative pain management. Patient and treatment factors were analyzed for associations with transfusion and morbidity. RESULTS: From 2001 through 2004, 367 patients underwent elective partial hepatectomy at Emory University Hospital. EA patients were more likely to be older, men, and with malignancy. There were no differences between the groups in extent of resection, operative time, blood loss, or starting hematocrit level. The EA group had lower mean arterial pressure in recovery (86.6+/-14.0 mmHg versus 94.5+/-13.2 mmHg, p < 0.001) and were more likely to be transfused with packed red cells during the hospital course (44.5% versus 27.9%, p < 0.001). On multivariate analysis, age greater than 65 years, American Society of Anesthesiologists grade>2, starting hematocrit<38%, operative time>300 minutes, blood loss>1 L, and use of EA were associated with increased numbers of patients receiving packed red blood cells. Complications and length of stay were similar for both groups. CONCLUSIONS: Epidural analgesia was independently associated with increased risk of packed red blood cell transfusion after hepatectomy. EA did not appear to minimize complications or shorten hospital stay. Caution should be exercised when considering EA use in hepatic resection.     

Portal vein resection and reconstruction prior to hepatic dissection during right hepatectomy and caudate lobectomy for hepatobiliary cancer

BACKGROUND: Hepatobiliary cancer invading the hilar bile duct often involves the portal bifurcation. Portal vein resection and reconstruction is usually performed after completion of the hepatectomy. This retrospective study assessed the safety and usefulness of portal vein reconstruction prior to hepatic dissection in right hepatectomy and caudate lobectomy plus biliary reconstruction, one of the common procedures for radical resection. METHODS: Clinical characteristics and perioperative results were compared in patients who underwent right hepatectomy and caudate lobectomy plus biliary reconstruction with (ten patients) and without (11 patients) portal reconstruction from September 1998 to March 2002. RESULTS: All ten portal vein reconstructions were completed successfully before hepatic dissection; the portal cross-clamp time ranged from 15 to 41 (median 22) min. Blood loss, blood transfusion during the operation, postoperative liver function, morbidity and length of hospital stay were similar in the two groups. No patient suffered postoperative hepatic failure or death. CONCLUSION: This study demonstrates that portal vein reconstruction does not increase the morbidity or mortality associated with right hepatectomy and caudate lobectomy with biliary reconstruction. This approach facilitates portal vein reconstruction for no-touch resection of hepatobiliary cancer invading the hilar bile duct.     

Excessive wastage of blood resources in elective colorectal surgery.

A prospective study of perioperative blood transfusion requirements for elective colorectal surgery over a 6-month period has been conducted. A total of 106 procedures was performed, 94 of which were for malignancy. A median of 2 units of packed red cells was cross-matched per patient. Twenty-three patients (21.7%) required a transfusion in the postoperative period. Fourteen of these patients required a second cross-match sample because their transfusion occurred more than 48 h after the original request. The greatest transfusion requirements were for patients undergoing abdominoperineal resection or subtotal colectomy. Routine perioperative cross-matching and reservation of blood for elective colorectal surgery may be an unnecessary expense, resulting in wastage of resources. A selective policy of serum being retained for grouping in these patients is justified.     

Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade

OBJECTIVE: To assess the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome. METHODS: Demographics, extent of resection, concomitant major procedures, operative and transfusion data, complications, and hospital stay were analyzed for 1,803 consecutive patients undergoing hepatic resection from December 1991 to September 2001 at Memorial Sloan-Kettering Cancer Center. Factors associated with morbidity and mortality and trends in operative and perioperative variables over the period of study were analyzed. RESULTS: Malignant disease was the most common diagnosis (1,642 patients, 91%); of these cases, metastatic colorectal cancer accounted for 62% (n = 1,021). Three hundred seventy-five resections (21%) were performed for primary hepatic or biliary cancers and 161 (9%) for benign disease. Anatomical resections were performed in 1,568 patients (87%) and included 544 extended hepatectomies, 483 hepatectomies, and 526 segmental resections. Sixty-two percent of patients had three or more segments resected, 42% had bilobar resections, and 37% had concomitant additional major procedures. The median blood loss was 600 mL and 49% of patients were transfused at any time during the index admission. Median hospital stay was 8 days, morbidity was 45%, and operative mortality was 3.1%. Over the study period, there was a significant increase in the use of parenchymal-sparing segmental resections and a decrease in the number of hepatic segments resected. In parallel with this, there was a significant decline in blood loss, the use of blood products, and hospital stay. Despite an increase in concomitant major procedures, operative mortality decreased from approximately 4% in the first 5 years of the study to 1.3% in the last 2 years, with 0 operative deaths in the last 184 consecutive cases. On multivariate analysis, the number of hepatic segments resected and operative blood loss were the only independent predictors of both perioperative morbidity and mortality. CONCLUSIONS: Over the past decade, the use of parenchymal-sparing segmental resections has increased significantly. The number of hepatic segments resected and operative blood loss were the only predictors of both perioperative morbidity and mortality, and reductions in both are largely responsible for the decrease in perioperative mortality, which has occurred despite an increase in concomitant major procedures.     

Acute isovolemic hemodilution during major hepatic resection—An initial report: Does it safely reduce the blood transfusion requirement?

Surgical resection remains the mainstay of treatment for patients with hepatic tumors, despite the associated morbidity including the need for blood transfusion. Acute isovolemic hemodilution (AIH) has been shown to decrease the transfusion requirement for cardiac, urologic, and orthopedic procedures. However, the reported experience with AIH during hepatic resections is limited. Seven patients underwent major hepatic resection from July 1992 to June 1994 with standard AIH. Their clinical parameters were compared with those of nine matched control patients during the same time period. AIH and control patients had similar preoperative laboratory values (hematocrit, bilirubin, and coagulation studies), extent of liver resection, and pathologic diagnoses. Mean tumor diameters were larger in the AIH group (9.3 cm vs. 5.8 cm). Most important, patients managed with AIH required homologous blood transfusions significantly less often than the control group (14% vs. 67%;P=0.05). Furthermore, if they did receive transfusions, AIH patients needed fewer units of red cells (0.1±0.1 units vs. 1.7±0.6 units). There was no morbidity associated with AIH. AIH can be safely performed in patients undergoing major hepatic resection for malignancy. AIH appears to reduce the number of patients requiring homologous blood transfusion as well as the number of units transfused per patient. This technique warrants further study in a larger prospective, randomized trial.     

Extrahepatic division of the right hepatic vein in right hepatectomy for blunt liver trauma

During a 5-year period, 10 patients with right-side blunt liver injury received an anatomic liver resection, using the technique of extrahepatic right hepatic vein division before hepatectomy. Five patients required a right posterior sectionectomy and 5 patients needed a right hemihepatectomy. The mean operation time was 146 minutes and median perioperative blood transfusion was 21.5 units (range, 4-94 units, packed red blood cell (PRBC) or whole blood). There was one hospital mortality; the patient died from multiple organs failure on postoperative day 5. Postoperative complications occurred in 4 of 9 surviving patients. Liver-related morbidity occurred in 2 patients who required reoperation for evacuation of subphrenic hematoma. The median hospital stay was 17 days (range, 6-84 days). Application of extrahepatic division of the right hepatic vein during a right hepatectomy for blunt liver trauma has several advantages: compression of a traumatic liver during mobilization; shortening of the ischemia duration; complete mobilization of the liver before parenchymal resection; and prevention of oozing with easier approximation of the raw surface.     

控制性低中心静脉压在腹腔镜肝叶切除术中的应用

目的:探讨控制性低中心静脉压(CLCVP)在腹腔镜肝叶切除术中应用的可行性及临床效果。方法:回顾性分析郑州大学第一附属医院2013年9月—2017年7月施行的腹腔镜肝切除术97例患者的临床资料,其中术中应用CLCVP者53例(CLCVP组),未应用CLCVP者44例(对照组),两组患者按照肝切除范围又分为腹腔镜简单肝叶切除术(左外叶切除、边缘部分不规则肝叶)与腹腔镜复杂肝脏切除术(左半肝切除、右半肝切除、肝中叶切除)亚组,比较两组患者总体与亚组间的相关临床指标。结果:全部患者均顺利完成手术,无围手术期死亡;无论总体还是亚组间比较,CLCVP组与对照组患者术中尿量、术后肝肾功能指标均无统计学差异(均P0.05);总体比较,CLCVP组与对照组切肝时间和术后住院时间亦均无统计学差异(均P0.05);CLCVP组术中出血量、输血例数、输血量均较对照组明显减少(P0.05);亚组比较,两组间腹腔镜简单肝叶切除术患者以上指标均无明显差异(均P0.05),但CLCVP组中腹腔镜复杂肝脏切除术患者的术中出血量、输血例数、输血量均明显少于对照组中腹腔镜复杂肝脏切除术患者(均P0.05);术后Clavien-Dindo III级以上并发症CLCVP组及对照组分别出现6例和5例(P0.05);全部患者术中及术后均未出现有临床症状的肺栓塞。结论:对于腹腔镜复杂性肝脏切除术患者,术中行CLCVP能有效减少出血量、输血量,且并无增加肺栓塞的危险。     

The failure of retrograde autologous priming of the cardiopulmonary bypass circuit to reduce blood use after cardiac surgical procedures

Hemodilution during cardiopulmonary bypass (CPB) is a primary risk factor for blood transfusion in cardiac surgical patients. Priming of the CPB circuit with the patients' own blood (retrograde autologous priming, RAP) is a technique used to limit hemodilution and reduce transfusion requirements. We designed this study to examine the impact of RAP on perioperative blood product use. Using a retrospective cohort study design, the medical records of all patients undergoing CPB (excluding circulatory arrest cases) by a single surgeon were examined. Data were collected over a 24-mo period when RAP was routinely used as a blood conservation strategy (RAP group, n = 257). This group was compared with a cohort of patients during the 24 mo immediately preceding the introduction of RAP into clinical practice (no RAP group, n = 288). A small, statistically insignificant reduction in the percentage of patients receiving packed red blood cells was observed in the RAP group (44% versus 51% no RAP, P = 0.083). No differences were found between the groups in the number of units of packed red blood cells, platelets, or fresh frozen plasma transfused throughout the perioperative period. These results suggest that overall, RAP does not offer a clinically important benefit as a blood conservation technique. IMPLICATIONS: Priming of the cardiopulmonary bypass circuit with the patients' own blood (retrograde autologous priming) resulted in insignificant reductions in blood use in a large, unselected group of patients undergoing cardiac surgical procedures.     

Autologous Versus Allogeneic Transfusions: No Difference in Perioperative Outcome After Partial Hepatectomy

Blood transfusion is often necessary in patients undergoing liver resection. Because of the risks associated with allogeneic blood products, preoperative autologous blood donation has been advocated, but its benefit with respect to perioperative outcome remains unclear. This study compares perioperative outcome in patients transfused only with autologous blood to a matched cohort receiving only allogeneic blood. All patients subjected to hepatic resection and given only perioperative autologous red cell transfusions were identified from a prospective database of 2,123 patients and reviewed retrospectively. This group was matched to patients transfused only with a comparable number of allogeneic red cell units and to a control group that received no blood products. All patients in the autologous or allogeneic group received either 1 or 2 U. Matching was based on age, comorbidity, extent of hepatic resection, and estimated blood loss. Matched pair analysis was performed using the paired t test, McNemar and Stuart–Maxwell tests. From December 1991 to May 2003, 124 patients undergoing hepatic resection received perioperative autologous blood only, for which optimal matching was possible in 104. The groups were similar with respect to age, comorbidities, and blood loss; the proportions receiving preoperative chemotherapy, requiring a major resection (≥3 segments) or a complex procedure (concomitant major procedure in addition to the principal hepatic resection) were also similar. There were no differences between the autologous and allogeneic groups in length of hospitalization, complications, and operative mortality. In patients undergoing hepatic resection, autologous blood transfusion did not demonstrably improve perioperative outcome when compared to a matched cohort of patients receiving a similar number of allogeneic units. To be presented at the 47th Annual Meeting of the Society of Surgery of the Alimentary Tract, May 20–24, 2006, Los Angeles, California.     

Evaluating variation in perioperative red blood cell transfusion for patients undergoing elective gastrointestinal cancer surgery

BackgroundPatients undergoing gastrointestinal cancer surgery often receive packed red blood cell transfusions. Understanding practice variation is critical to support efforts working toward responsible transfusion use. We measured the extent and importance of variation in perioperative packed red blood cell transfusion use across physicians and hospitals among gastrointestinal cancer surgery patients.MethodsWe identified patients who underwent elective gastrointestinal cancer resection between 2007 and 2019 using linked administrative health data sets in Ontario, Canada. We used funnel plots to describe variation in transfusion use, adjusted for patient case mix. Hierarchical regression models quantified patient-level, between-physician, and between-hospital variation in transfusion use with R² measures, variance partition coefficients, and median odds ratios.ResultsOf 59,964 included patients (median age 69 years; 43.2% female; 75.8% colorectal resections), 18.0% received perioperative packed red blood cell transfusions. Funnel plots showed variation in transfusion use among physicians and hospitals. Patient characteristics, such as age, comorbidity, and procedure type, combined to explain 12.8% of the variation. After adjusting for case mix, systematic between-physician and between-hospital differences were responsible for 2.8% and 2.1% of the variation, respectively. This translated to an approximately 30% difference in the odds of transfusion for 2 similar patients treated by distinct physicians (median odds ratio: 1.35, 95% confidence interval 1.30–1.40) and hospitals (median odds ratio: 1.30, 95% confidence interval 1.23–1.42). We observed comparable effects across procedure-type subgroups.ConclusionTransfusion provision is highly driven by patient factors. Yet the impact of the treating physician and hospital on variation relative to other factors is important and reflects opportunities to target modifiable processes of care to standardize perioperative packed red blood cell transfusion practice.     

A prospective evaluation of ultrasound-directed transparenchymal vascular control with linear cutting staplers in major hepatic resections

BACKGROUND: We prospectively evaluated a novel ultrasound-directed technique of major hepatic resection using transparenchymal application of vascular staplers intending to minimize blood loss, operative time, and hepatic warm ischemia time. METHODS: Beginning in 1998 many major hepatic resections for hepatic tumors were performed with ultrasound-directed transparenchymal application of vascular linear cutting staplers. An endoscopic flexible neck vascular linear cutting stapler was used for control of the hepatic veins. RESULTS: From December 1998 to April 2003, 346 patients undergoing hepatic resection using this technique were identified from a prospective hepatobiliary tumor surgery database. Records were reviewed for blood loss, transfusion requirement, inflow occlusion (Pringle maneuver) time, overall operative time, and perioperative and postoperative complications. The average blood loss for all patients was 396 +/- 28.4 mL. The inflow occlusion time was 13.7 +/- .64 minutes with a total operative time of 140.7 +/- 3.7 minutes. Additional liver-related procedures were performed in 52% of the patients. The overall complication rate was 29.5% with a 90-day mortality rate of 1.4%. CONCLUSIONS: Ultrasound-directed transparenchymal application of vascular staplers to control inflow and outflow during major liver resection minimizes blood loss, warm ischemia time, and operative time compared to published reports of patients undergoing resection using other techniques.     

The role of the ultrasonically activated shears and vascular cutting stapler in hepatic resection

Hemorrhage and liver failure are the two greatest concerns for patients undergoing major liver resection. Inflow occlusion (Pringle maneuver) is often used to minimize blood loss, but hepatic ischemia results in an increased risk of postoperative hepatic dysfunction. We report our experience with the Harmonic Scalpel ultrasonically activated shears (UAS; Ethicon Endo-Surgery, Cincinnati, OH) and a vascular stapler for hepatic resection as technological advances that aid in minimizing blood loss and thereby reduce the need for inflow occlusion. We retrospectively reviewed liver resections performed from September 1997 through July 1998, in which the UAS and articulating vascular endoscopic linear cutting stapler were used. The vascular stapler was used to divide the appropriate portal vein branch and hepatic vein(s) before parenchymal transection. Parenchymal dissection was performed with UAS to a depth of approximately 2 to 3 cm, and the remainder of the liver parenchyma was divided by a clamp crush and clip and suture ligate technique. Patients underwent segmental resection (n = 12), lobectomy (n = 13), or extended lobectomy (n = 11). Resection was performed for metastatic disease, primary liver tumors, or benign disease in 21, 8, and 7 patients, respectively. A Pringle maneuver was performed in 7 of 36 patients (mean clamp time, 8 minutes). The median required intraoperative blood transfusion was 0 units of packed red blood cells. Major and minor complications occurred in 12 and 3 patients, respectively. Two deaths were related to pneumonia and abdominal infection. The vascular stapler safely and securely divides portal vein branches and hepatic veins. The UAS initiates parenchymal transection with minimal blood loss. These two technologies facilitate the surgeon's aim of liver resection without blood transfusion or Pringle maneuver.     

Morbidity of major hepatic resections: a 100-case prospective study.

OBJECTIVE: To assess the morbidity and its main risk factors after major hepatic resection. DESIGN: Retrospective study of prospectively collected data. SETTING: University hospital, France. SUBJECTS: 100 consecutive patients who underwent major hepatic resections, 1989-95. INTERVENTIONS: Major hepatic resection, defined as resection involving 3 or more segments according to Couinaud's classification, in all cases. MAIN OUTCOME MEASUREs: All complications that affected outcome or prolonged hospital stay. Risk factors identified by univariate and multivariate analysis. RESULTS: 45 patients developed at least 1 complication and 7 died. The most common complications were: pleural effusion (n = 21), hepatic failure (n = 12), and ascites (n = 9). Univariate analysis showed that the following variables were significantly related to the morbidity: age >55 years, American Society of Anesthesiologists (ASA) grade II or more, bilirubin >80 micromol/L, alkaline phosphatase activity more than double the reference range, malignant tumours, abnormal liver parenchyma, simultaneous surgical procedures, operative time >4 hours, and perioperative blood transfusion > or =600 ml. The extent of resection did not correlate with postoperative complications. Multivariate analysis showed that volume of blood transfusion > or =600 ml and simultaneous surgical procedures were the most important independent risk factors for complicated outcome. CONCLUSIONS: The morbidity associated with major hepatic resections remains high, and the main determinants of outcome are intraoperative surgeon-related factors.     

Aprotinin reduces postoperative bleeding and the need for blood products in thoracic surgery: results of a randomized double-blind study

Objective: Bleeding complications have been a major concern in certain thoracic surgery operations, especially decortication and pulmonary resection for inflammatory pulmonary infection. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood consumption. Methods: Use of blood products (packed red cells, whole blood), chest tube drainage, analgesic requirement, chest tube duration for the patients undergoing major thoracic operations were recorded. In a double blind randomized fashion, patients were assigned to two groups receiving aprotinin (n=51) at a loading dose of 10⁶ kallikrein inhibitory units (KIU) followed by an infusion of the same dose during chest closure or receiving placebo (n=52). On a daily basis, red-cell percentages of total fluid from drainage bottles were recorded and using the blood hematocrit level of the patient of the day before, the corrected value for the patient's blood volume equivalent of daily drainage was calculated. Results: There was a significant reduction in perioperative use of donor blood (0.98±0.92 vs. 0.45±0.32 unit; P=0.0026), and total chest tube drainage (corrected value for the corresponding blood volume) (28.2±36.9 vs. 76.9±53.3 ml, P=0.0004) (mean±standard deviation) in the aprotinin group. However, aprotinin did not reduce postoperative transfusion or decrease in hematocrit level due to thoracic operations. In high transfusion-risk thoracic surgery patients (patients who underwent decortication, pulmonary resection for inflammatory lung disease and chest wall resection), the perioperative transfusion was only 0.50±1.08 units in aprotinin group, compared with 1.94±0.52 units in control group (P=0.003). Postoperative transfusion was also reduced in aprotinin administrated group (0.53±0.56 vs. 1.38±0.97 units; P=0.02). The mean total blood loss was decreased to nearly one third of the blood loss of the control group (41±28 ml vs. 121±68 ml; P=0.001). Conclusion: Aprotinin significantly reduced perioperative transfusion requirement and postoperative bleeding during major thoracic operations. Aprotinin decreased perioperative transfusion needs. Moreover, patients who were at risk of greater blood loss during and after certain thoracic operations had a greater potential to benefit from prophylactic perioperative aprotinin treatment.     

Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries

BACKGROUND: Pulmonary tractotomy was introduced in 1994 as a novel concept for lung salvage after penetrating wounds. Recently, tractotomy has been suggested to increase morbidity and, thus, its practice has been challenged. The purpose of this study was to compare the morbidity and mortality associated with nonanatomic and anatomic lung resection in the management of severe pulmonary injuries. METHODS: Using our trauma registry, patients admitted to an urban Level I trauma center during an 11-year period with thoracic injuries requiring thoracotomy and pulmonary operation were identified. A chart review was performed with attention to patient demographics, operative treatment, and outcome. Pulmonary operations performed were classified as either nonanatomic (wedge resection and tractotomy) or anatomic resection (lobectomy and pneumonectomy). Statistical analysis was performed using Student's test, Fisher's exact test, and logistic regression as appropriate. RESULTS: There were 34 men and 2 women, with a mean age of 29 +/- 2 years. Mechanism of injury was predominantly penetrating, with 26 (72%) gunshot wounds and 8 (22%) stab wounds. Intraoperative blood loss and early red blood cell transfusion requirement were lower in patients undergoing nonanatomic resection (3.85 L vs. 11.90 L and 17.4 U vs. 27.9 U, respectively; p < 0.05). Mortality was 4% in the nonanatomic resection group versus 77% in the anatomic resection group. CONCLUSION: Nonanatomic resection is associated with an improved morbidity and mortality compared with anatomic resection in the management of severe lung injuries. Although not a randomized study, these findings encourage the continued application of lung-sparing procedures when feasible.     

Left hepatic trisectionectomy for hepatobiliary malignancy: results and an appraisal of its current role

OBJECTIVE: To analyze results of 70 patients undergoing left hepatic trisectionectomy and to clarify its current role. SUMMARY BACKGROUND DATA: Left hepatic trisectionectomy remains a complicated hepatectomy, and few reports have described the long-term results of the procedure. METHODS: Short-term and long-term outcomes of 70 consecutive patients who underwent left hepatic trisectionectomy from January 1993 to February 2004 were analyzed. RESULTS: Of the 70 patients, 36 had colorectal liver metastasis, 24 had cholangiocarcinoma, 4 had hepatocellular carcinoma, and the remaining 6 had other tumors. Overall morbidity, 30-day and 90-day mortality rates were 46%, 7%, and 9%, respectively. Multivariate analysis disclosed that preoperative jaundice and intraoperative blood transfusion were positive independent predictors for postoperative morbidity; however, there were no independent predictors for postoperative mortality. Postoperative morbidity (87% versus 35%, P < 0.001) and mortality (20% versus 5%, P = 0.108) were observed more frequently in patients with preoperative obstructive jaundice than in those without jaundice. Each survival according to tumor type was acceptable compared with reported survivals. Survival for patients with colorectal liver metastasis undergoing left hepatic trisectionectomy with concomitant partial resection of the remnant liver was similar to those without this concomitant procedure. This concomitant procedure was not associated with postoperative morbidity and mortality. CONCLUSIONS: Left hepatic trisectionectomy remains a challenging procedure. Preoperative obstructive jaundice considerably increases perioperative risk. Concomitant partial resection of the remaining liver appears to be safe and offers the potential for cure in patients with colorectal metastasis affecting all liver segments.     

Prognostic significance of perioperative blood transfusion in oral cavity squamous cell carcinoma

BACKGROUND: The influence of perioperative blood transfusion on survival in squamous cell carcinoma of the head and neck is still not convincingly determined. To investigate the effect of perioperative allogeneic transfusion on survival in stage II-IV squamous cell carcinoma of the oral cavity, we studied a consecutive series of 105 patients undergoing primary tumor resection and neck dissection. METHODS: Retrospective analyses were performed using Cox proportional hazards models with 16 variables. RESULTS: Perioperative red blood cell transfusion was required in 64 (61%) patients. Multivariate analysis demonstrated that the number of positive nodes and > or =3 units of red blood cell transfusion were an independent prognostic indicators. The calculated odds ratio for death after > or =3 units transfused was 5.79 (95% confidence interval, 1.56-21.53, p <.01). CONCLUSIONS: More than 3 units of allogeneic red blood cells transfused might shorten the survival of patients with oral cavity cancer.     

Changes in red blood cell transfusion practice during the past quarter century: a retrospective analysis of pediatric patients undergoing elective scoliosis surgery using the Mayo database

Background contextPrevious studies have demonstrated significant changes in red blood cell (RBC) transfusion practice over several decades.PurposeThe purpose of the present study was to ascertain changes in transfusion practice during a 25-year study epoch and determine whether these changes had any impact on the frequency of perioperative morbidity and mortality in pediatric patients undergoing major spine surgery.Study designRetrospective chart review.Patient samplePediatric patients undergoing elective scoliosis surgery.Outcome measuresImpact of RBC transfusion on perioperative morbidity and mortality.MethodsPediatric patients undergoing elective scoliosis surgery were stratified into one of two transfusion-related groups: 1975 to 1985 (ie, pre–human immunodeficiency virus screening, early practice group, n=177) or 1990 to 2000 (ie, recent practice group, n=192). Transfusion and perioperative outcome data were obtained from medical records. Red blood cell use was analyzed as a continuous variable and compared between groups using the Wilcoxon rank sum test, as were preoperative, postoperative, and discharge hemoglobin concentration. Age-adjusted data were compared between groups using chi-square or Fisher exact tests.ResultsPatients in the recent practice group had significantly worse comorbid disease and more complex procedures compared with those in the early practice group. The percentage of patients in the recent practice group receiving allogeneic RBC transfusions was significantly less than the early group (37.5% vs. 89.8%, p<.001). Utilization of autologous RBC and intraoperative autotransfusion was significantly greater in the recent practice group (5.1% vs. 47.4% and 20.9% vs. 95.8%, respectively). Hemoglobin concentrations were significantly lower for all time periods in the recent practice group. There were no differences in major morbidity or mortality between groups.ConclusionsIn this retrospective review, we report a significant change in blood management strategies in pediatric patients undergoing elective scoliosis surgery. We demonstrated a shift from utilization of allogeneic RBC transfusion toward preoperative donation and intraoperative autotransfusion. Although transfusion triggers were significantly lower in the recent practice group, we were unable to demonstrate a difference in major morbidity or mortality. Utilization of autologous RBC transfusion was safe and effective in reducing allogeneic RBC transfusions in this study. The advantages of autologous blood transfusion may be in preserving a relatively scarce resource (ie, allogeneic blood), rather than mitigating transfusion-related complications.     

Transfusion medicine: does treatment of anemia reduce costs to the national health system?

Preoprative Anaemia is an independent risk factor in perioperative medicine. Furthermore, preoperative anaemia is associated with higher treatment costs and remains the main risk factor for the transfusion of packed red blood cells. However, transfusion of packed red blood cells is although life-saving in conditions of acute anaemia associated with higher mortality, morbidity and postoperative complications. The preoperative treatment of anaemia has been shown to improve postoperative outcome and transfusion requirements. Treatment of anemia as one pillar of patient blood management bears the potential to reduce costs to the national health system by prevention of complications and transfusion-associated morbidity. The economic impact of the treatment of preoperative anaemia versus the treatment with blood products requires prospective evaluation.     

Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database

OBJECTIVE: To assess the trends in perioperative outcome of hepatectomy for hepatobiliary diseases. METHODS: Data of 1222 consecutive patients who underwent hepatectomy for hepatobiliary diseases from July 1989 to June 2003 in a tertiary institution were collected prospectively. Perioperative outcome of patients in the first (group I) and second (group II) halves of this period was compared. Factors associated with morbidity and mortality were analyzed. RESULTS: Diagnoses included hepatocellular carcinoma (n = 734), other liver cancers (n = 257), extrahepatic biliary malignancies (n = 43), hepatolithiasis (n = 101), benign liver tumors (n = 61), and other diseases (n = 26). The majority of patients (61.8%) underwent major hepatectomy of > or = 3 segments. The overall hospital mortality and morbidity were 4.9% and 32.4%, respectively. The number of hepatectomies increased from 402 in group I to 820 in group II, partly as a result of more liberal patient selection. Group II had more elderly patients (P = 0.006), more patients with comorbid illnesses (P = 0.001), and significantly worse liver function. Nonetheless, group II had lower blood loss (median 750 versus 1450 mL, P < 0.001), perioperative transfusion (17.3% versus 67.7%, P < 0.001), morbidity (30.0% versus 37.3%, P = 0.012), and hospital mortality (3.7% versus 7.5%, P = 0.004). On multivariate analysis, hypoalbuminemia, thrombocytopenia, elevated serum creatinine, major hepatic resection, and transfusion were the significant predictors of hospital mortality, whereas concomitant extrahepatic procedure, thrombocytopenia, and transfusion were the predictors of morbidity. CONCLUSIONS: Perioperative outcome has improved despite extending the indication of hepatectomy to more high-risk patients. The role of hepatectomy in the management of hepatobiliary diseases can be expanded. Reduced perioperative transfusion is the main contributory factor for improved outcome.