Modified laparoscopic and open splenectomy and azygoportal disconnection for portal hypertension

Background

Laparoscopic splenectomy and azygoportal disconnection has been reported safe, feasible and minimally invasive for patients with portal hypertension. We have developed an even less invasive technique, modified laparoscopic splenectomy and azygoportal disconnection, and compared outcomes of modified laparoscopic splenectomy and azygoportal disconnection and open splenectomy and azygoportal disconnection in patients with portal hypertension.

Methods

We retrospectively evaluated outcomes in 107 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism who underwent modified laparoscopic splenectomy and azygoportal disconnection (n = 37) or open splenectomy and azygoportal disconnection (n = 70) between January 2010 and February 2013. Their demographic, intraoperative, and postoperative variables were compared.

Results

Modified laparoscopic splenectomy and azygoportal disconnection was successful in all patients, with none requiring conversion to open surgery or having significant perioperative complications. Operation time was significantly longer for modified laparoscopic splenectomy and azygoportal disconnection than open splenectomy and azygoportal disconnection (P < 0.0001), but estimated intraoperative blood loss (P = 0.0004); volume of intraoperative blood transfusion (P < 0.05); visual analog scale pain score on the first postoperative day (P < 0.0001); times to first oral intake (P < 0.0001), passage of flatus (P = 0.0004), and off-bed activity (P < 0.0001); postoperative hospital stay (P < 0.0001); postoperative days of temperature >38.0 °C (P = 0.002); white blood cell counts on postoperative days 1 (P < 0.0001) and 7 (P < 0.05) were significantly reduced in the modified laparoscopic splenectomy and azygoportal disconnection group. The percentage of patients experiencing postoperative complications was significantly lower in the modified laparoscopic splenectomy and azygoportal disconnection group than in the open splenectomy and azygoportal disconnection group (13.5 % [5/37] vs. 35.7 % [25/70], P < 0.05).

Conclusions

The less invasive modified laparoscopic splenectomy and azygoportal disconnection group is a feasible, effective, and safe surgical procedure for liver cirrhosis patients with portal hypertensive bleeding and hypersplenism.     

Laparoscopic partial splenectomy is safe and effective in patients with focal benign splenic lesion

Background

Traditionally, splenectomy is considered as the treatment for splenic lesions. The risk of early and late complications and the awareness of immunologic function of spleen have pushed the development of spleen sparing techniques. This study aimed to evaluate the safety and feasibility of laparoscopic partial splenectomy in selected patients.

Methods

From May 2011 we initiated performing laparoscopic partial splenectomy in patients with focal benign splenic lesion. The main surgical procedure consisted of four steps: 1. Mobilizing the perisplenic ligaments. 2. Ligating and dissecting the vessels which supplying the involved spleen. 3. Dissecting the spleen along the demarcation. 4. Hemostasis was achieved by bipolar energy device. The perioperative data were collected and analyzed. The follow-up including quality of life and splenic regrowth was routinely undergone 6 months after surgery.

Results

From May 2011 to December 2013, laparoscopic partial splenectomy had been performed on 11 patients aged from 13 to 57 (mean 33). The indications included nonparasitic cyst (n = 6), lymphangioma (n = 3), and hemangioma (n = 2). The mean operative time was 148 min (range 110–200 min). The mean estimated blood loss was 189 ml (range 100–400 ml). One patient converted to total splenectomy because of hemorrhaging. Two patients suffered from postoperative complications: the one who converted to total splenectomy suffered from portal vein thrombosis, the other one underwent partial splenectomy suffered from fluid collection around splenic recess. There was no blood transfusion and postoperative mortality. All patients discharged uneventfully. Seven patients finished the follow-up including evaluation of CT scan and quality of life 6 month after surgery. The results demonstrated all these patients had different degree of splenic regrowth and gained a good quality of life.

Conclusions

Laparoscopic partial splenectomy is safe and effective in patients with focal benign splenic lesion. Meanwhile, this technique potentially retains some splenic function, and confers the benefit of a minimal access technique.     

Intravenous flurbiprofen for post-thymectomy pain relief in patients with myasthenia gravis

Background

The use of CoSeal?, a polyethylene glycol sealant, in cardiac and vascular surgery for prevention of anastomotic bleeding has been subject to prior investigations. We analysed our perioperative data to determine the clinical benefit of using polyethylene glycol sealant to inhibit suture line bleeding in aortic surgery.

Methods

From January 2004 to June 2006, 124 patients underwent aortic surgical procedures such as full root replacements, reconstruction and/or replacement of ascending aorta and aortic arch procedures. A Bentall procedure was employed in 102 of these patients. In 48 of these, a polyethylene glycol sealant was added to the anastomotic closure of the aortic procedure (sealant group) and the other 54 patients did not have this additive treatment to the suture line (control group).

Results

There were no significant between-group differences in the demographic characteristics of the patients undergoing Bentall procedures. Mean EuroSCORES (European System for Cardiac Operative Risk Evaluation) were 13.7?±?7.7 (sealant group) and 14.4?±?6.2 (control group), p?=?NS. The polyethylene glycol sealant group had reduced intraoperative and postoperative transfusion requirements (red blood cells: 761?±?863 versus 1248?±?1206?ml, p?=?0.02; fresh frozen plasma: 413?±?532 versus 779?±?834?ml, p?=?0.009); and less postoperative drainage loss (985?±?972 versus 1709?±?1302?ml, p?=?0.002). A trend towards a lower rate of rethoracotomy was observed in the sealant group (1/48 versus 6/54, p?=?0.07) and there was significantly less time spent in the intensive care unit or hospital (both p?=?0.03). Based on hypothesis-generating calculations, the resulting economic benefit conferred by shorter intensive care unit and hospital stays, reduced transfusion requirements and a potentially lower rethoracotomy rate is estimated at ?1,943 per patient in this data analysis.

Conclusions

The use of this polymeric surgical sealant demonstrated improved intraoperative and postoperative management of anastomotic bleeding in Bentall procedures, leading to reduced postoperative drainage loss, less transfusion requirements, and a trend towards a lower rate of rethoracotomy. Hypothesis-generating calculations indicate that the use of this sealant translates to cost savings. Further studies are warranted to investigate the clinical and economic benefits of CoSeal in a prospective manner.     

Revisiting vascular patency after spleen-preserving laparoscopic distal pancreatectomy with conservation of splenic vessels

Background

We evaluated vascular patency and potential changes in preserved spleens after laparoscopic spleen-preserving distal pancreatectomy (SPDP) with conservation of both splenic vessels.

Methods

We retrospectively analyzed the patency of conserved splenic vessels in patients who underwent laparoscopic or robotic splenic vessel-conserving SPDP from January 2006 to August 2010. The patency of the conserved splenic vessels was evaluated by abdominal computed tomography and classified into three grades according to the degree of severity.

Results

Among 30 patients with splenic vessel-conserving laparoscopic SPDP, 29 patients with complete follow-up data were included in this study. During the follow-up period (median: 13.2?months), grades 1 and 2 splenic arterial obliteration were observed in one patient each. A total of five patients (17.2%) showed grade 1 or 2 obliteration in conserved splenic veins. Most patients (82.8%) had patent conserved splenic vein. Four patients (13.8%) eventually developed collateral venous vessels around gastric fundus and reserved spleen, but no spleen infarction was found, and none presented clinical relevant symptoms, such as variceal bleeding. There was no statistical difference in vascular patency between the laparoscopic and robotic groups (P?>?0.05).

Conclusions

Most patients showed intact vascular patency in conserved splenic vessels and no secondary changes in the preserved spleen after laparoscopic splenic vessel-conserving SPDP.     

Allogeneic blood transfusion reduction by risk-based protocol in total joint arthroplasty

Purpose

To evaluate the effect of a preoperative protocol that triages patients awaiting total joint arthroplasty to one of four strategies designed to mitigate the risk of allogeneic blood transfusion (ABT) based on a priori transfusion risk on perioperative exposure to allogeneic blood.

Methods

We compared the transfusion experiences of a historical control series of 160 subjects with a study group of 160 subjects treated by protocol. Protocol subjects with hemoglobin (Hb) 100-129 g·L^?1 were given erythropoietin, dosed by weight. Subjects with Hb 130-139 g·L^?1 underwent preoperative autologous blood harvest and perioperative re-infusion as deemed clinically necessary. Subjects with Hb >139 g·L^?1 received no special intervention, unless they were aged >70 yr and weighed < 70 kg, in which case they received oral iron and folate supplementation.

Results

The relative risk of ABT in the Study group was 0.68 (95% confidence interval 0.54-0.85). The Control group received 104 units of allogeneic blood and the Study group received 35 units (P = 0.0007). These differences cannot be explained by differences in transfusion risk or autologous units transfused. There was no worsening of anemia or its consequences in the Study group.

Conclusion

A simple protocol based on easily obtained preoperative clinical indices effectively targets interventions that mitigate the risk of ABT.     

Perioperative Blood Transfusion Is Associated with Decreased Survival in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Adenocarcinoma: a Multi-institutional Study

Introduction

In this multi-institutional study of patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma, we sought to identify factors associated with perioperative transfusion requirement as well as the association between blood transfusion and perioperative and oncologic outcomes.

Methods

The surgical databases across six high-volume institutions were analyzed to identify patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma from 2005 to 2010. For statistical analyses, patients were then stratified by transfusion volume according to whether they received 0, 1–2, or >2 units of packed red blood cells.

Results

Among 697 patients identified, 42 % required blood transfusion. Twenty-three percent received 1–2 units, and 19 % received >2 units. Factors associated with an increased transfusion requirement included older age, heart disease, diabetes, longer operative time, higher blood loss, tumor size, and non-R0 margin status (all p?p?=?0.02) and overall survival (14.0 vs. 21.0 months, p?2 units (hazard ratio, 1.92, p?=?0.009) and postoperative transfusions as independent factors associated with decreased disease-free survival.

Conclusions

This multi-institutional study represents the largest series to date analyzing the effects of perioperative blood transfusion on patient outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma. While blood transfusion was not associated with increased rate of infectious complications, allogeneic blood transfusion did confer a negative impact on disease-free and overall survival.     

Targeted Preoperative Autologous Blood Donation in Total Knee Arthroplasty Reduces the Need for Postoperative Transfusion

Background

Preoperative donation of autologous blood has been widely used to minimize the potential risk of allogeneic transfusions in total knee arthroplasty. A previous study from our center revealed that preoperative autologous donation reduces the allogeneic blood exposure for anemic patients but has no effect for non-anemic patients.

Questions/Purposes

The current study investigates the impact of a targeted blood donation protocol on overall transfusion rates and the incidence of allogeneic blood transfusions.

Methods

Prospectively, 372 patients undergoing 425 unilateral primary knee replacements were preoperatively screened by the Blood Preservation Center between 2009 and 2012. Anemic patients with a hemoglobin level less than 13.5 g/dL were advised to donate blood, while non-anemic patients did not donate.

Results

Non-anemic patients who did not donate blood required allogeneic blood transfusions in 5.9% of the patients. The overall rate of allogeneic transfusion was significantly lower for anemic patients who donated autologous blood (group A, 9%) than those who did not donate (group B, 33%; p?<?0.001). Donating autologous blood did increase the overall transfusion rate of anemic patients to 0.84 per patient in group A compared to 0.41 per patient in group B (p?<?0.001).

Conclusion

This investigation confirms that abandoning preoperative autologous blood donation for non-anemic patients does not increase allogeneic blood transfusion rates but significantly lowers overall transfusion rates.     

Laparoscopic splenectomy for massive splenomegaly in benign hematological diseases

Background

Laparoscopic splenectomy has become the standard of care for benign hematological disease affecting the spleen; its role in massive splenomegaly remains controversial. In this study, we evaluated the outcome of laparoscopic splenectomies in terms of spleen size in a group of 83 patients of benign hematological diseases.

Methods

From July 2003 to December 2009, 83 patients underwent laparoscopic splenectomy for various benign hematological diseases. The data were recorded and analyzed in a retrospective manner. The patients were divided in to two groups according to the spleen weight; group I?<?2,000?g (n?=?54) and group II?>?2,000?g (n?=?29). Age, sex, hematological condition, operative time, estimated blood loss, conversion to open surgery, splenic weight, length of hospital stay, time to liquid diet, and morbidity were all recorded.

Results

Laparoscopic splenectomy was completed in 79 patients (95.2?%). Operative time (p?=?0.01) and estimated blood loss (p?=?0.001) was more in group II. The length of hospital stay (p?=?0.05) and the postoperative morbidity (p?=?0.001) also were significantly more in the second group. There was no mortality.

Conclusions

Laparoscopic splenectomy is possible and safe for massive splenomegaly in hematological disease (>2,000?g), but it needs longer operative time and hospital stay.     

Do Perioperative Blood Transfusions Influence Prognosis of Gastric Cancer Patients? Analysis of 927 Patients and Interactions with Splenectomy

Background

This study was to assess the influence of perioperative blood transfusions on the prognosis of patients undergoing a potentially curative resection for gastric cancer and to investigate the interaction between transfusions and splenectomy.

Materials and Methods

Between January 1990 and December 2005, 927 patients from 6 Italian tertiary referral centers underwent curative resections for gastric cancer. Clinical and pathologic variables were prospectively collected. The influence of perioperative blood transfusions on survival were evaluated by univariate and multivariate analysis. Moreover, the influence of splenectomy both in transfused and nontransfused patients undergoing total gastrectomy was also evaluated.

Results

The overall 5-year survival was 54.6%. The 5-year survival rate in transfused patients (n = 327) was 50.6% compared with 56.6% in nontransfused patients (n = 600) (P = .094). In the subgroup of patients who underwent total gastrectomy with spleen preservation (n = 209), 5-year survival rate was 46% and 51.4% in transfused and nontransfused patients, respectively (P = .418); those who underwent total gastrectomy with splenectomy (n = 199) presented a 5-year survival rate of 45% in transfused group compared with 39.1% in nontransfused patients (P = .571).

Conclusions

Our study indicates a slightly, but not significantly, negative effect of allogeneic blood transfusion on prognosis of gastric cancer patients. In the subgroup of patients who underwent total gastrectomy, splenectomy seems to invert this mild effect, with a positive influence on overall survival.     

A Meta-Analysis of Perioperative Outcomes of Laparoscopic Splenectomy for Hematological Disorders

Background

Due to changes in surgical trends, laparoscopic splenectomy (LS) has become the standard approach for most splenectomies performed for hematological disorders, barring any contraindications. The perioperative outcomes of LS for this indication have not been updated for several years. Controversy still surrounds whether LS should be performed for massive splenomegaly. The purpose of this meta-analysis was to evaluate the perioperative outcomes of laparoscopic splenectomy for hematological disorders.

Methods

Literature searches were conducted to identify studies comparing the perioperative outcomes of the laparoscopic and open approaches for hematological disorders. The results were pooled by using standard meta-analysis methods.

Results

Thirty-eight studies with a total of 2,914 patients comparing LS to open splenectomy (OS) for hematological disorders were identified. Mortality was low in both groups. The pooled complications of the LS group were significantly fewer than those of the OS group (?0.11, p?<?0.001), and the NNT was 9 (95?% confidence interval, 6–20). For massive spleens, a similar result was observed (?0.12, p?=?0.009). Accessory spleen resection and blood loss also were comparable between the two approaches. Additionally, LS was associated with longer operative times (57.38?min, p?<?0.00001) and shorter hospital stays (2.48?days, p?<?0.00001).

Conclusions

LS is preferred compared to OS, based on lower complication rates and better handling of comorbid conditions. LS is associated with shorter hospital stays but longer operative times. We conclude that LS may be considered an acceptable option even in cases of a massive spleen. To strengthen the clinical evidence, more high-quality clinical trials on different issues are necessary.     

Laparoscopic Splenectomy and Azygoportal Disconnection: a Systematic Review

Background and Objectives:

Given the technical difficulty of laparoscopic splenectomy and azygoportal disconnection (LSD), data are limited that compare the laparoscopic to the open procedure. As the technique becomes more widespread, questions regarding its safety, feasibility, and reproducibility must be addressed. This review assesses the current status of LSD.

Methods:

We conducted our literature review with a search of the PubMed database. All published series of 5 or more laparoscopic splenectomy and azygoportal disconnection procedures were examined. The demographic, intraoperative, and postoperative data analyzed included number of ports, conversion rate, operative duration, estimated intraoperative blood loss, postoperative hospital stay, and complications.

Results:

Fifteen articles met the review criteria. Of 412 laparoscopic procedures, traditional laparoscopic splenectomy and azygoportal disconnection (TLSD) was used in 322 patients (78.2%), a modified laparoscopic procedure (MLSD) in 79 (19.2%), and a single-incision laparoscopic procedure (SLSD) in 11 (2.7%). Compared with the traditional and single-incision laparoscopic procedures, the MLSD procedure was associated with shorter operative duration and less blood loss. Furthermore, although the incidence of postoperative portal vein system thrombosis was higher in the laparoscopic than in the open splenectomy with azygoportal disconnection (OSD) procedure, the LSD procedure was associated with less pulmonary infection and pleural effusion and fewer incisional and overall complications than the open procedure. The rate of conversion to an open procedure was 5.4%.

Conclusions:

LSD is feasible and safe for selected patients when performed by an expert laparoscopic surgeon. It has perioperative advantages over OSD, but studies with longer follow-up periods and larger samples of patients are needed.     

Heparin and protamine titration do not improve haemostasis in cardiac surgical patients

Purpose

Weight-based heparin and protamine dosing strategies for cardiopulmonary bypass (CPB) do not take into account interpatient variability in drug sensitivity and may result in bleeding complications. We compared the Hemochron® RxDx heparin and protamine titration system with standard weight based management with regard to heparin dose, protamine dose, and perioperative bleeding.

Methods

One hundred and thirty-five cardiac surgical patients were randomised into four groups. Group I received standard heparin and protamine management: Group 2 received heparin and protamine byin vitro titration. Group 3 had the heparin dose titrated, and group 4 had the protamine dose titrated. Coagulation tests, bleeding, and transfusion requirements were measured.

Results

The initial heparin bolus predicted by the titration was < 300 U· kg^?1 in all patients. Group 2 received a lower heparin bolus for the initiation of bypass but total heparin doses were not different among groups (group 1 = 365 ± 43, group 2= 348 ± 73 U · kg^?1, group 3= 394 ± 86 U · kg^?1, group 4= 376 ± 60; P = 0.06). Groups 2 and 4 received a lower initial and a lower total protamine dose (total dose group 1 = 4.03 ± 0.65 mg · kg^?1, group 2 = 3.56 ±1.11 mg · kg^?1, group 3= 4.22 ± 0.90 mg · kg^?1, group 4= 3.38 ± 0.98 mg· kg^?1,P = 0.001). The incidences of incomplete heparin neutralisation (P = 0.14) and heparin rebound (P = 0.1) were not different among groups. Postoperative bleeding and transfusion requirements did not differ.

Conclusion

In cardiac surgical patients, heparin and protamine titration did predict a lower protamine dose but did not result in a measurable improvement in haemostasis during the perioperative period.     

Effect of Donor Right Hepatectomy on Splenic Volume and Platelet Count for Living Donor Liver Transplantation

Background

Donor hepatectomy for living donor liver transplantation accompanies physio-morphological changes of the liver and spleen. Therefore, the long-term consequences of these organs should be characterized to ensure donor's safety.

Methods

A total of 382 right liver harvests for liver transplantation were performed from October 2000 to February 2011. Clinical parameters across donor operations were compared, and the associations were investigated.

Results

The remaining liver grew continually, reaching 81.5?±?11.2 % of the entire liver until 6 months after donation. The spleen grew to 143.1?±?28.8 % of the pre-donation value within 1 week after surgery, and thereafter, its size decreased gradually to 130.6?±?25.1 % at 6 months. At 6 months post-donation, 48.1 % (114/237) of donors showed an increase of ≥30 % in splenic volume, and 15.9 % (50/315) of donors exhibited a decrease of ≥30 % in platelet count. However, patients with splenic enlargement and/or decrease in platelet count at 6 months post-donation were not different in liver function, liver regeneration, or overall complications.

Conclusions

Although splenic enlargement and/or decrease in platelet count can persist for more than 6 months after donation in patient population after donor right hepatectomy, such a change did not impact donor's safety.     

Laparoscopic splenectomy and azygoportal disconnection for bleeding varices with hypersplenism

BACKGROUND: Bleeding from esophageal varices is an important cause of morbidity and mortality in patients with portal hypertension. The ideal surgical procedure should control bleeding with as little impairment of liver function as possible and with low rates of encephalopathy. Recently, significant progress in laparoscopic technology has enabled laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach in a less invasive way. In this paper, we present preliminary results for 25 patients in whom laparoscopic splenectomy and azygoportal disconnection were performed. PATIENTS AND METHODS: Laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach were performed in 25 patients with cirrhosis, bleeding portal hypertension, and secondary hypersplenism between January 2000 and October 2006. Among them, 5 patients underwent a laparoscopic modified Sugiura procedure, the lower esophagus was transected, and then reanastomosed with a circular stapler. RESULTS: Laparoscopic splenectomy and azygoportal disconnection were completed in all patients, except in 1 conversion, without significant morbidity. The operation time ranged from 4.0 to 5.5 hours and the blood loss was 100-400 mL. The postoperative hospital stay was 6-15 days. During a postoperative follow-up period of 3 months to 5 years in 22 patients, neither esophagus variceal bleeding nor encephalopathy has recurred. CONCLUSIONS: Laparoscopic splenectomy and azygoportal disconnection are feasible, effective, and safe surgical procedures, and have all the benefits of minimally invasive surgery for patients with bleeding portal hypertension and hypersplenism. Laparoscopic splenectomy and azygoportal disconnection offer a new operative method for treatment of bleeding portal hypertension with hypersplenism.     

Cinacalcet effects on the perioperative course of patients with secondary hyperparathyroidism

Purpose

Since its registration in 2004, the calcimimetic agent cinacalcet has been established as an alternative treatment for secondary hyperparathyroidism (SHPT). Working by allosteric activation of the calcium-sensing receptor, cinacalcet can lower parathyroid hormone (PTH) and calcium (Ca) in patients with SHPT. The influence of calcimimetics on the perioperative course has been unclear so far.

Methods

We retrospectively analyzed the data of patients with primary operation for SHPT between 2004 and 2011, comparing the perioperative course of patients with and without preoperative cinacalcet treatment.

Results

Fifty-six patients had cinacalcet therapy, and 54 patients had no calcimimetic medication prior to surgery. Gender, age, hemodialysis, and medical treatment were similar in both groups. Also, PTH levels were similar preoperatively and postoperatively (preoperative, 1,249?±?676 vs. 1,196?±?601 pg/ml; postoperative, 86?±?220 vs. 62?±?91 pg/ml). Patients with cinacalcet preoperatively had significant lower Ca levels preoperatively (2.49?±?0.25 vs. 2.61?±?0.24 mmol/l) and postoperatively (1.75?±?0.37 vs. 1.86?±?0.35 mmol/l) and had a higher rate of oral Ca substitution postoperatively (93 vs. 74 %). The risk for postoperative persistent disease was slightly higher in these patients compared to those without preoperative cinacalcet therapy (5 vs. 0 %, not significant).

Conclusions

In our experience, cinacalcet did not alter the perioperative course in SHPT patients.     

Trends and Risk Factors for Transfusion in Hepatopancreatobiliary Surgery

Introduction

Patient-specific factors impacting the need for possible perioperative blood transfusions have not been examined in patients undergoing hepatopancreatobiliary (HPB) procedures. We sought to define the overall utilization of blood transfusions for HPB surgery stratified by procedure type, as well as identify patient-level risk factors for transfusion.

Methods

Hepatic and pancreatic resections were selected from the 2005–2011 American College of Surgeons National Surgical Quality Improvement Program's public use files. Transfusion utilization, risk factors, temporal trends, and outcomes were assessed using regression models. Missing data were addressed using multiple imputation.

Results

Twenty-six thousand eight hundred twenty-seven patients met the inclusion criteria. There were 16,953 pancreas cases (distal pancreatectomy (31.2 %), pancreaticoduodenectomy (65.8 %), total pancreatectomy (3.0 %)), and 9,874 liver cases (wedge resection (60.0 %), hemi-hepatectomy (30.1 %), trisegmentectomy (9.9 %)). Overall, 25.7 % patients received a perioperative transfusion. Transfusion rates varied by operation type (hepatic wedge resection 18.7 %, lobectomy 31.3 %, trisegmentectomy 39.8 %, distal pancreatectomy 19.8 %, Whipple 28.7 %, total pancreatectomy 43.6 %, p?<?0.001). On multivariate analysis, several patient-level factors were strongly associated with the risk of transfusion: preoperative hematocrit <36 % (risk ratios (RR) 1.99, 95 % CI 1.91–2.08), preoperative albumin <3.0 g/dL (RR 1.25, 95 % CI 1.19–1.31), American Society of Anesthesiologists (ASA) class IV (RR 1.24, 95 % CI 1.16–1.33), and anticoagulation/bleeding disorder (RR 1.26, 95 % CI 1.15–1.38) (all p?<?0.001). Patients with any one of these high-risk factors had an over twofold increased risk of perioperative transfusion (RR 2.31, 95 % CI 2.21–2.40, p?<?0.001).

Conclusion

There are large differences in the incidence of transfusion among patients undergoing HPB procedures. While the type of HPB procedure was associated with the risk of transfusion, patient-level factors—including preoperative hematocrit and albumin, ASA classification, and history of anticoagulation/bleeding disorder—were as important.     

Routine Anterior Approach During Right Hepatectomy: Results of a Prospective Randomised Controlled Trial

Trial Design

A prospective randomised controlled trial was designed to evaluate the advantages of routine application of the anterior approach during right hepatectomy.

Methods

The study was conducted between March 2005 and April 2009 in a tertiary hepatobiliary?Cpancreatic centre. Patients scheduled for right hepatectomy for primary or metastatic tumours, without infiltration of segment 1, inferior vena cava or main bile duct, were randomly assigned to right hepatectomy using either an anterior or a classic approach. The primary study endpoint was overall blood loss.

Results

Sixty-six patients were randomly allocated to undergo right hepatectomy with an anterior (AA group n?=?33) or a classic approach (CA group n?=?33). Sixty-five patients were included in the analysis (33 in AA group and 32 in CA group). There was no significant difference in patient age, diagnosis, preoperative hepatic biochemistry and tumour size between the two groups. Overall blood loss (437?ml?±?664 in AA group vs.500?ml?±?532.3 in CA group; p?=?0.960) and bleeding during transection (p?=?0.973) were similar between two groups. Perioperative blood transfusion rates were 18?% in the AA group and 9.3?% in the CA group (p?=?0.253). Time of parenchymal transsection was significantly longer in AA group (75.1?±?26.6?min vs. 56.7?±?17.5?min, p?=?0.01). There was no difference between both groups for postoperative prothrombin time, serum transaminase and total bilirubin levels. One patient died in each group (p?=?0.746). The two groups had similar morbidity rates.

Conclusion

Routine application of the anterior approach during right hepatectomy does not decrease intraoperative blood loss and morbidity rate.     

Stapleless Laparoscopic Splenectomy with Individual Vessel Dissection in Patients with Splenomegaly

Background

Mechanical stapling devices have been established as a mainstay in laparoscopic splenectomy (LS), but limited data are available regarding stapleless LS for splenomegaly with individual vessel dissection (IVD). This study aimed to investigate the feasibility of stapleless LS for splenomegaly and its potential advantage over staple-based LS.

Methods

A total of 51 patients with splenomegaly underwent stapleless LS and were subsequently reviewed. The data collected include the patients’ demographics, operative outcomes, and the rates of conversion to open surgery, complications, and mortality. Multiple linear and logistic regression analyses were used to assess the impact of the primary diagnosis, body mass index (BMI), and massive splenomegaly on the perioperative conversion rate.

Results

There were no deaths. The mean for various parameters are as follows: spleen length 21.6 cm; spleen weight 1,184 g, operating time 148 min, hospital stay 5.2 days, estimated blood loss 245 ml. The total conversion rate was 9.8 % (including one reoperation for bleeding). The presence of a BMI >30 % and hematologic malignancy—cofactors of portal hypertension (PH)—and a spleen weight >1,000 g were independent predictors of conversion to open surgery.

Conclusions

Stapleless LS for splenomegaly is feasible and safe in selected patients. It has advantages over traditional procedures using staples, at least in patients with benign splenomegaly. Patients with hematologic malignancy, BMI >30 %, coexistence of PH, and spleen weight >1,000 g are susceptible to bleeding during dissection of the splenic hilum, with use of IVD being relatively limited.     

Preoperative use of epoietin beta in total hip replacement: a prospective study

Objective

Epoietin (EPO) effectively decreases perioperative blood transfusion requirements. We evaluated the feasibility of using EPO beta to increase haemoglobin levels before total hip replacement (THR) and reduce transfusion.

Materials and methods

One hundred and seventy-one patients undergoing primary THR were included in this prospective observational study. Patients with initial haemoglobin level <130 g l^?1 received EPO beta subcutaneously in a four-dose regimen. Haemoglobin levels were measured at baseline, before surgery, and at postoperative days 1 and 5.

Results

Twenty-eight patients received EPO beta preoperatively, 143 were not treated including 42 with initial haemoglobin level <130 g l^?1. Haemoglobin increased by 29 ± 9 g l^?1 in the low Hb + EPO group versus 2 ± 1 g l^?1 for the other patients. In the low Hb + EPO group 3.6% were transfused, in the low HB group 45.2% (P = 0.001) and in the normal Hb group 11.9% (P = 0.2).

Conclusions

Preoperative EPO beta increases haemoglobin level and reduces transfusion frequency in anaemic patients before total joint replacement. It could play a major role in the management of perioperative blood loss in orthopaedic surgery.     

Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy

Background

Although laparoscopic splenectomy has been gradually regarded as an acceptable therapeutic approach for patients with massive splenomegaly, intraoperative blood loss remains an important complication. In an effort to evaluate the most effective and safe treatment of splenomegaly, we compared three methods of surgery for treating splenomegaly, including open splenectomy, laparoscopic splenectomy, and a combination of preoperative splenic artery embolization plus laparoscopic splenectomy.

Methods

From January 2006 to August 2011, 79 patients underwent splenectomy in our hospital. Of them, 20 patients underwent a combined treatment of preoperative splenic artery embolization and laparoscopic splenectomy (group 1), 30 patients had laparoscopic splenectomy alone (group 2), and 29 patients underwent open splenectomy (group 3). Patients’ demographics, perioperative data, clinical outcome, and hematological changes were analyzed.

Results

Preoperative splenic artery embolization plus laparoscopic splenectomy was successfully performed in all patients in group 1. One patient in group 2 required an intraoperative conversion to traditional open splenectomy because of severe blood loss. Compared with group 2, significantly shorter operating time, less intraoperative blood loss, and shorter postoperative hospital stay were noted in group 1. No marked significant differences in postoperative complications of either group were observed. Compared with group 3, group 1 had less intraoperative blood loss, shorter postoperative stay, and fewer complications. No significant differences were found in operating time. There was a marked increase in platelet count and white blood count in both groups during the follow-up period.

Conclusions

Preoperative splenic artery embolization with laparoscopic splenectomy reduced the operating time and decreased intraoperative blood loss when compared with laparoscopic splenectomy alone or open splenectomy. Splenic artery embolization is a useful intraoperative adjunctive procedure for patients with splenomegaly because of the benefit of perioperative outcomes.