Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy

Background

Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped.

Objective

Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors.

Design, setting, and participants

A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n = 22) or without anatomic VMD (group 2; n = 22) performed by a single surgeon from April 2010 to January 2011.

Intervention

Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary.

Measurements

Baseline, perioperative, and postoperative data were collected prospectively.

Results and limitations

Group 1 tumors were larger (4.3 vs 2.6 cm; p = 0.011), were more often hilar (41% vs 9%; p = 0.09), were medial (59% and 23%; p = 0.017), were closer to the hilum (1.46 vs 3.26 cm; p = 0.0002), and had a lower C index score (2.1 vs 3.9; p = 0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p = 0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1 h), median blood loss (200 and 100 ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3 mg/dl). The study was limited by the relatively small sample size.

Conclusions

Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.     

A population-based analysis of temporal perioperative complication rates after minimally invasive radical prostatectomy

Background

Existing population-based reports on complication rates after minimally invasive radical prostatectomy (MIRP) did not address temporal trends.

Objective

To examine contemporary temporal trends in perioperative MIRP outcomes.

Design, setting, and participants

Between 2001 and 2007, 4387 patients undergoing MIRP were identified using the Nationwide Inpatient Sample.

Measurements

To examine the rates and trends of intraoperative and postoperative complications, transfusion rates, length of stay in excess of the median, and in-hospital mortality. We tested the effect of the late (2006-2007) versus the early (2001-2005) study period on all outcomes using multivariable logistic regression models controlled for clustering among hospitals.

Results and limitations

Intraoperative and postoperative complications decreased from 7.0% to 0.8% (p < 0.001) and from 28.5% to 8.7% (p < 0.001), respectively. Transfusion rates decreased from 3.5% to 2.1% (p = 0.3). Hospital length of stay >2 d decreased from 56% to 15% (p < 0.001). In multivariable analyses, intraoperative (odds ratio [OR]: 0.41; p = 0.002) and postoperative (OR: 0.65; p = 0.007) complications were less frequent in the late versus the early study period. Late study period patients were less likely to stay >2 d than early study period patients (OR: 0.34; p > 0.001). Limitations of these findings include the lack of adjustment for several patient variables including disease characteristics, surgeon variables including surgeon caseload, and the restriction to in-hospital events.

Conclusions

Our analyses demonstrate that in-hospital complication rates and length of stay after MIRP decreased over time. This implies that temporal differences specific to complication rates after MIRP must be considered when comparisons are made with other radical prostatectomy techniques.     

Impact of biventricular and left ventricular pacing on hemodynamics and left ventricular dyssynchrony compared with right ventricular pacing in the early postoperative period following cardiac surgery

Objectives

The aims of this study were to test the hypotheses that in the postoperative period following corrective surgery for congenital heart defects: (i) atrio-right ventricular (RA-RV) pacing decreases cardiac output (CO) compared with right atrial (RA) pacing, (ii) atrio-biventricular (RA-BiV) and left ventricular (RA-LV) pacing improves CO compared with RA-RV pacing.

Study design

Prospective observational study.

Patients

Children 0-2 years of age referred for surgery of congenital heart defects were studied during intrinsic rhythm and atrial, atrio-right ventricular, atrio-left ventricular and atrio-biventricular pacing. CO, extrapolated from mean systolic aortic velocity (MSAV), and left ventricular dyssynchrony were assessed using transthoracic echocardiography.

Results

RA-RV pacing induced a significant decrease in CO (MSAV 0.52 ± 0.19 m/s to 0.46 ± 0.16 m/s, p = 0.01) and a significant increase in LV dyssynchrony (8.7 ± 7.9 ms to 33 ± 21 ms, p = 0.001). RA-BiV pacing induced a significant increase in CO (MSAV 0.46 ± 0.16 m/s to 0.52 ± 0.18 m/s, p = 0.01) and a significant decrease in LV dyssynchrony (33 ± 21 ms to 7 ± 4 ms, p = 0.0003) compared with RA-RV pacing. RA-LV pacing induced a significant decrease in LV dyssynchrony (33 ± 21 ms to 9 ± 7 ms, p = 0.0007) without a significant improvement of CO compared with RA-RV pacing.

Conclusions

RA-BiV pacing improves CO compared with RA-RV pacing in the early postoperative period following pediatric cardiac surgery. This improvement is related to a reduction in left ventricular dyssynchrony.     

Intraoperative Continuous Norepinephrine Infusion Combined with Restrictive Deferred Hydration Significantly Reduces the Need for Blood Transfusion in Patients Undergoing Open Radical Cystectomy: Results of a Prospective Randomised Trial

Background

Open radical cystectomy (ORC) is associated with substantial blood loss and a high incidence of perioperative blood transfusions. Strategies to reduce blood loss and blood transfusion are warranted.

Objective

To determine whether continuous norepinephrine administration combined with intraoperative restrictive hydration with Ringer's maleate solution can reduce blood loss and the need for blood transfusion.

Design, setting, and participants

This was a double-blind, randomised, parallel-group, single-centre trial including 166 consecutive patients undergoing ORC with urinary diversion (UD). Exclusion criteria were severe hepatic or renal dysfunction, congestive heart failure, and contraindications to epidural analgesia.

Intervention

Patients were randomly allocated to continuous norepinephrine administration starting with 2 μg/kg per hour combined with 1 ml/kg per hour until the bladder was removed, then to 3 ml/kg per hour of Ringer's maleate solution (norepinephrine/low-volume group) or 6 ml/kg per hour of Ringer's maleate solution throughout surgery (control group).

Outcome measurements and statistical analysis

Intraoperative blood loss and the percentage of patients requiring blood transfusions perioperatively were assessed. Data were analysed using nonparametric statistical models.

Results and limitations

Total median blood loss was 800 ml (range: 300–1700) in the norepinephrine/low-volume group versus 1200 ml (range: 400–2800) in the control group (p < 0.0001). In the norepinephrine/low-volume group, 27 of 83 patients (33%) required an average of 1.8 U (±0.8) of packed red blood cells (PRBCs). In the control group, 50 of 83 patients (60%) required an average of 2.9 U (±2.1) of PRBCs during hospitalisation (relative risk: 0.54; 95% confidence interval [CI], 0.38–0.77; p = 0.0006). The absolute reduction in transfusion rate throughout hospitalisation was 28% (95% CI, 12–45). In this study, surgery was performed by three high-volume surgeons using a standardised technique, so whether these significant results are reproducible in other centres needs to be shown.

Conclusions

Continuous norepinephrine administration combined with restrictive hydration significantly reduces intraoperative blood loss, the rate of blood transfusions, and the number of PRBC units required per patient undergoing ORC with UD.     

Predictors of warm ischemia time and perioperative complications in a multicenter, international series of robot-assisted partial nephrectomy

Background

Warm ischemia time (WIT) and complication rates are two important parameters for evaluating the perioperative results of robot-assisted partial nephrectomy (RAPN). Few data are available about the clinical predictors of WIT and overall complications.

Objective

To identify clinical predictors of WIT and perioperative complications.

Design, setting, and participants

This is a retrospective study including 347 patients who underwent RAPN for suspicious renal cell carcinoma (RCC) at four referral centers from September 2008 to September 2010.

Intervention

All patients underwent RAPN using the da Vinci S Surgical System with hilar clamping.

Measurements

WIT >20 min and overall complication rates were the main outcomes. Postoperative complications were classified according to the Clavien/Dindo system. Moreover, the following perioperative variables were considered: clinical tumor size, anatomical tumor characteristics according to Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification score, surgeon experience, console time, blood loss, and upper collecting system (UCS) repair.

Results and limitations

WIT >20 min was reported in 125 (36%) cases. Intraoperative and postoperative complications were observed in 10 (2.9%) and 41 (11.8%) cases, respectively. Surgeon experience (odds ratio [OR]: 6.381; 95% confidence interval [CI], 3.687-11.042; p < 0.001), clinical tumor size (OR: 1.022; 95% CI, 1.002-1.044; p = 0.03), the other anatomic characteristics determined by the PADUA classification score (OR: 1.294; 95% CI, 1.080-1.549; p = 0.005), and the UCS repair (OR: 2.987; 95% CI, 1.728-5.165; p < 0.001) turned out to be independent predictors of WIT >20 min. Similarly, surgeon experience (OR: 3.937; 95% CI, 2.011-7.705; p < 0.001), clinical tumor size (OR: 1.033; 95% CI, 1.009-1.058; p = 0.007), and the other anatomical characteristics determined by the PADUA classification score (OR: 1.427; 95% CI, 1.149-1.773; p < 0.001) turned out to be independent predictors of overall complication rates. The retrospective design is the main limitation of this multicenter, international study. Therefore, some patient characteristics and comorbidities were not recorded.

Conclusions

Anatomic tumor characteristics as determined by the PADUA classification score were independent predictors of WIT and overall complications, once adjusted for the effects of surgeon experience and clinical tumor size.     

Clopidogrel and bleeding in patients undergoing elective coronary artery bypass grafting

Objective

In an effort to minimize transfusions in patients undergoing elective coronary artery bypass grafting operations after recent clopidogrel exposure, we studied laboratory tests predictive of platelet dysfunction and used a strict algorithm-driven treatment of bleeding.

Methods

Forty-five patients receiving clopidogrel within 6 days of the operation and 45 control subjects were studied. Prothrombin time, activated partial thromboplastin time, platelet count, and platelet function test results were measured before heparinization, after protamine administration, and then every 2 hours. No transfusions were administered unless a patient met both laboratory and clinical criteria.

Results

Algorithm-driven treatment of bleeding significantly reduced the mean units of all blood components transfused by about one third, as shown by comparison with current control and historical data. Compared with current control subjects, clopidogrel recipients required significantly more transfusions of platelets (9.0 ± 1.7 vs 1.2 ± 0.5 U; P < .0001) and packed red blood cells (4.3 ± 0.6 vs 2.3 ± 0.5 U; P = .01) and required longer periods of controlled ventilation (12.4 ± 1.3 vs 8.6 ± 0.8 hours; P = .02). Preoperative platelet dysfunction before heparin administration for cardiopulmonary bypass, as measured by using adenosine diphosphate aggregometry (response <40%), predicted all but 1 case of severe coagulopathy requiring multiple transfusions (16.6 ± 2.8 U of platelets and 5.8 ± 1.0 U of packed red blood cells).

Conclusions

A strict transfusion algorithm can reduce the transfusion requirement for all blood components. Preheparin testing of platelet function with adenosine diphosphate aggregometry can identify patients at highest risk for perioperative bleeding and transfusions and might further reduce the perioperative transfusion requirement.     

Factors influencing neck anteversion during femoral nailing: a retrospective analysis of 220 torsion-difference CTs

Background

Rotational malalignment is a well-known complication following intramedullary nailing of femoral shaft fractures. The hypothesis of this study is that various modifiable factors, such as position on the surgical table or nailing technique, influence the incidence of torsional abnormalities.

Methods

For this retrospective study, we analysed the data of 220 consecutive patients with femoral shaft fractures and postoperative torsion-difference computed tomographies (CTs), performed from 2001 to 2009 in our institution. Mean age of the patients was 33 ± 15 years. Average delay to surgery was 8 ± 11 days. The average postoperative neck anteversion difference between both sides was 11 ± 8°. A p value <0.05 was considered to be statistically significant.

Results

The average postoperative neck anteversion difference between both sides was not significantly affected from the position of the patient on the surgical table (supine or lateral, p = 0.698), the delay till surgery (p = 0.989), the nailing technique (antegrade or retrograde, p = 0.793; reamed or unreamed, p = 0.930), the type of the implant (p = 0.885) and the experience of the surgeon (p = 0.055). Furthermore, the learning curve regarding this complication was long and not predictable.

Conclusions

We could not identify any risk factors that are associated with an increased incidence of torsional deformities, and thus our hypothesis could not be confirmed. The inability to identify such risk factors renders the prevention of this complication particularly problematic. The invention of new techniques for better intra-operative control of the torsion is probably the only solution to further reduce the incidence of postoperative malrotational deformities.     

Exsanguination protocol improves survival after major hepatic trauma

Background

Hepatic injury remains an important cause of exsanguination after major trauma. Recent studies have noted a dramatic reduction in mortality amongst severely injured patients when trauma exsanguinations protocols (TEP) are employed. We hypothesised that utilisation of our institution's TEP at the initiation of hospital resuscitation would improve survival in patients with significant hepatic trauma.

Patients and methods

All patients who (1) sustained intra-abdominal haemorrhage with Grades III-V hepatic injury and (2) underwent immediate operative intervention between February 2004 and January 2008 were included in the study. TEP was instituted in February 2006, and all subsequent patients who met inclusion criteria and were treated with TEP constituted the study group. Patients who met inclusion criteria, were treated before introduction of TEP, and received at least 10 units packed red blood cells in the first 24 h constituted pre-TEP comparison group. Univariate and multivariate analyses evaluated the effects of TEP on the study population.

Results

Seventy-five patients were included in the study: 39 in the pre-TEP cohort (31% 30-day survival) and 36 in the TEP cohort (53% 30-day survival). There were no differences in demographics, extent of hepatic injury, or operative approach between the patient groups (all p ≥ 0.27). Injury Severity Scores were significantly higher in the TEP group (41 ± 18 vs. 28 ± 15, p < 0.01). TEP patients received more plasma and platelets during operative intervention and significantly less crystalloid (all p < 0.01). Occurrence of cardiac dysfunction and abdominal compartment syndrome was significantly lower in TEP patients who survived 24-h post-injury (both p ≤ 0.04). After adjusting for the significant negative effects of Grade V injury and involvement of major hepatic vasculature (both p ≤ 0.02), TEP significantly improved 30-day survival: OR = 0.22, 95% CI: 0.06-0.81, p = 0.02.

Conclusions

TEP allows for an effective use of plasma and platelets during intra-operative management of severe hepatic injury. Utilisation of TEP is associated with significant reductions of cardiac dysfunction and development of abdominal compartment syndrome, as well as, significant improvement in 30-day survival.     

Does clopidogrel increase blood loss following coronary artery bypass surgery?

Background

Clopidogrel (Plavix) is a potent inhibitor of platelet aggregation used concomitantly with percutaneous coronary interventions and in patients with acute coronary syndromes. Its favorable effects on preventing thrombus formation may have deleterious effects on hemostasis in patients undergoing coronary surgery.

Methods

Data were collected prospectively on 312 consecutive urgent or emergent coronary artery bypass patients from July 1999 through April 2001 at a tertiary care center. Patients were stratified into three groups: clopidogrel within 4 days of operation (n = 41), clopidogrel continued until 5 to 8 days before operation (n = 39), and clopidogrel discontinued more than 8 days before operation or were never taking clopidogrel (n = 232).

Results

Preoperative and intraoperative characteristics were similar among all groups. Mediastinal and pericardial chest tube losses in the first 24 hours were 1,044 ± 750 mL in the clopidogrel within 4 days group, 528 ± 250 mL in the clopidogrel 5 to 8 days group, and 573 ± 329 mL in the clopidogrel more than 8 days group (p < 0.01). The mean total blood product transfusions were 12.2 ± 15.4 U, 1.2 ± 2.0 U, and 2.6 ± 5.7 U, respectively (p < 0.001). Reoperation for bleeding was noted in 14.6%, 2.6%, and 1.7%, respectively (p = 0.002). The median hospital lengths of stay for the three groups were 9 days, 7 days, and 7 days, respectively (p = 0.018). There were no statistically significant differences in mortality rate, myocardial infarction, stroke, mediastinitis, or postoperative renal failure among the groups. Multivariable analysis revealed that clopidogrel within 0 to 4 days of operation was an independent predictor of transfusion requirements (OR 4.22, 95% confidence interval [CI] 2.07, 9.34, p = 0.001), intensive care unit (ICU) length of stay (OR 3.14, 95% CI 1.40, 7.04, p = 0.006), and total hospital length of stay (coefficient 7.65, se 2.41, p = 0.002).

Conclusions

Clopidogrel within 4 days of coronary bypass surgery is associated with increased blood losses and reoperation for bleeding and, according to multivariable models, is an independent risk factor for increased transfusion requirements and prolonged ICU and hospital length of stay.     

Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center

Background

Penetrating injuries to the chest present a frequent and challenging problem, but the majority of these injuries can be managed non-\operatively. The aim of this study was to describe the incidence of penetrating chest trauma and the ultimate techniques used for operative management, as well as the diagnosis, complications, morbidity and mortality.

Methods

A retrospective 9-year review of patients who underwent an operative procedure following penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung injury scale score, concomitant injuries, time from admission to operating room, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded.

Results

A total of 1123 patients who were admitted with penetrating thoracic trauma were investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within 24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their mean age was 25.72 ± 9.33 (range, 15-54) years. The mean LOS was 10.65 ± 8.30 (range, 5-65) days. Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound (gunshot, 13.53 ± 9.92 days; stab wound, 8.76 ± 6.42 days, p < 0.001). Patients who died had a significantly lower systolic blood pressure (SBP) on presentation in the emergency room (42.94 ± 36.702 mm Hg) compared with those who survived (83.96 ± 27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8% (n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients with gunshot wounds (p = 0.29). Concomitant abdominal injuries (p = 0.01), diaphragmatic injury (p = 0.01), ISS (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001), blood transfusion volume (p < 0.01) and SBP (p = 0.001) were associated with mortality.

Conclusion

Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing techniques have become the most frequently used procedures for lung injuries. The presence of associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS, chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and associated abdominal injury.     

Blood loss during extensive escharectomy and auto-microskin grafting in adult male major burn patients

Purpose

To improve the accuracy of blood loss estimation during extensive escharectomy and auto-microskin grafting on extremities in adult male major burn patients.

Method

All adult male major burn patients admitted to our center who underwent extensive escharectomy and auto-microskin graft on extremities for more than 10%TBSA during the period 1 January 2008 to 31 December 2009 were involved in this study. The blood loss during the operation was estimated by the surgeons or calculated according to the changes in hemoglobin levels.

Results

The average burn and escharectomy areas for the 64 burn patients included in the study were 74.16 ± 16.96% and 30.27 ± 15.63%TBSA respectively. The auto-microskin donor area was 3.81%TBSA. The volumes of intra-operative calculated and estimated blood losses and transfused blood during the operation were 0.47 ml/cm², 0.13 ml/cm² and 0.20 ml/cm² surgical area 77.29 ml, 20.51 ml and 32.83 ml per 1%TBSA), respectively. Within two weeks after injury surgical blood loss appeared to be greater the later the operation was carried out. Within the first week after injury the mean proportional blood loss was increased with area excised.

Conclusion

In this study the average calculated blood loss for the operation of extensive escharectomy and microskin graft in adult male major burn patient was 0.47 ml/cm² (77.29 ml per 1% TBSA). This result will help us to predict expected blood loss more accurately.     

The hidden blood loss after hip fracture

Introduction

Despite advances in surgical and anaesthetic techniques the mortality after hip fracture has not significantly changed in the last 40 years. Pre-operative anaemia is a risk factor for peri-operative death.We speculate that a significant proportion of the blood loss related to hip fractures has occurred prior to surgery. Identifying patients at risk of pre-operative anaemia can facilitate appropriate medical optimisation. This study is unique in its attempt to quantify the blood loss associated with the initial hip injury.

Methods

In a retrospective study all patients with both a diagnosis of hip fracture and an operative delay of >48 h were assessed. The information collected included: fracture classification, serial haemoglobins and patient co-morbidities. The exclusion criteria included a pre-injury diagnosis of anaemia, anti-coagulation and gastrointestinal bleeds.

Results

Between 2007/2008 sixty-eight intracapsular and fifty extracapsular hip fracture patients had serial haemoglobins and operative delays of >48 h (mean 75 h, range 48-270 h). The mean lowest recorded haemoglobin prior to surgery for both extracapsular and intracapsular fractures were 95.0 g/L (±SEM 2.2) and 108.5 g/L (±SEM 2.2) respectively. This difference was statistically significant (Student's t-test p < 0.05).The mean haemoglobin drop in the extracapsular and intracapsular fracture groups was 20.2 g/L (range 0-49 g/L) and 14.9 g/L (range 0-59 g/L) respectively.

Conclusions

Hip fracture patients have a large drop in haemoglobin that is associated with the initial trauma rather than the operation. This highlights the need for anaesthetic and orthopaedic staff to be vigilant to the risk of pre-operative anaemia in this cohort of frail patients even when the initial haemoglobin is apparently normal.     

Tranexamic acid reduces haematomas but not pain after total knee arthroplasty

Aim

Tranexamic acid (TxA) reduces total blood losses (TBL) and allogenic transfusion (TH) after total knee arthroplasty (TKA). TBL can be external (surgical field, drains), or hidden (haematomas). Haematomas induce pain and limit postoperative rehabilitation. The aim of the study was to evaluate if TxA reduces haematomas and pain after TKA.

Study design

Prospective non-randomized study.

Method

After ethical committee approvement and written informed consent, the patients planned for a primary TKA were included (control group followed by a TxA group, 15 mg/kg before incision and at skin closure). General anaesthesia and analgesia were standardized (sciatic block, continuous femoral block, ketamine, ketoprofene, paracetamol, PCA with morphine). Volume of haematomas = TBL (calculated based on haemograms performed the day before surgery, and at postoperative day 5, and on transfusions) - measured external bleeding. Patients were followed up for 8 days, and at postoperative day 180 (by phone). Fifty patients per group allowed the detection of a 50% morphine sparing at day 8 (α = 0.05 and β = 0.2), and a 25% reduction of haematoma volumes at day 5.

Results

Perioperative data, pain scores and functional parameters (until day 180) were not different between control group patients (n = 52) and TxA group patients (n = 55): morphine consumption at day 8 was respectively 35 ± 32 and 42 ± 38 mg (P = 0.29). Yet, TxA reduced hematoma volumes (526 ± 202 versus 337 ± 165 mL of red blood cells, P < 0.0001) and clinically apparent hematomas. Morphine consumptions at day 8 and haematoma volumes were not correlated.

Conclusion

After TKA, TxA reduces the volume of hematomas, without any improvement in analgesia and rehabilitation until the sixth postoperative month.     

Laparoendoscopic single-site upper urinary tract surgery: assessment of postoperative complications and analysis of risk factors

Background

Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to minimise the morbidity and scarring associated with surgical intervention.

Objective

To evaluate the incidence of and the risk factors for complications in patients undergoing LESS upper urinary tract surgery.

Design, setting, and participants

Between September 2007 and February 2011, 192 consecutive patients underwent LESS for upper urinary tract diseases at four institutions.

Measurements

All complications occurring at any time after surgery were captured, including the inpatient stay as well as in the outpatient setting. They were classified as early (onset <30 d), intermediate (onset 31-90 d), or late (onset >90 d) complications, depending on the date of onset. All complications were graded according to the modified Clavien classification.

Results and limitations

The patient population was generally young (mean: 55 ± 18 yr of age), nonobese (mean body mass index [BMI]: 26.5 ± 4.8 kg/m²), and healthy (mean preoperative American Society of Anaesthesiologists [ASA] score: 2 ± 1). Forty-six patients had had prior abdominal surgery. Mean operative time was 164 ± 63 min, with a mean estimated blood loss (EBL) of 147 ± 221 ml. In 77 cases (40%), the surgeons required additional ports, with a standard laparoscopy conversion rate of 6%. Mean hospital stay was 3.3 ± 2.3 d, and the mean visual analogue scale (VAS) score at discharge was 1.7 ± 1.43. Thirty-three complications were recorded—30 early, 2 intermediate, and 1 late—for an overall complication rate of 17%. Statistically significant associations were noted between the occurrence of a complication and age, ASA score, EBL, length of stay (LOS), and malignant disease at pathology. Univariable and the multivariable analyses showed that a higher ASA score (incidence rate ratio [IRR]: 1.4; 95% confidence interval [CI], 1.0-2.1; p = 0.034) and malignant disease at pathology (IRR: 2.5; 95% CI, 1.3-4.7; p = 0.039) represented risk factors for complications. Poisson regression analysis over time showed a 23% non-statistically significant reduction in risk of complications every year (IRR: 0.77; 95% CI, 0.5-1.19; p = 0.242).

Conclusions

Malignant disease at pathology and high ASA score represent a predictive factor for complication after LESS for upper urinary tract surgery. Thus, surgeons approaching LESS should start with benign diseases in low-surgical-risk patients to minimise the likelihood of postoperative complications.     

Robotic Partial Nephrectomy with Superselective Versus Main Artery Clamping: A Retrospective Comparison

Background

Concerns have been raised regarding partial nephrectomy (PN) techniques that do not occlude the main renal artery.

Objective

Compare the perioperative outcomes of superselective versus main renal artery control during robotic PN.

Design, setting, and participants

A retrospective analysis of 121 consecutive patients undergoing robotic PN using superselective control (group 1, n = 58) or main artery clamping (group 2, n = 63).

Intervention

Group 1 underwent tumor-specific devascularization, maintaining ongoing arterial perfusion to the renal remnant at all times. Group 2 underwent main renal artery clamping, creating global renal ischemia.

Outcome measurements and statistical analysis

Perioperative and functional data were evaluated. The Pearson chi-square or Fisher exact and Wilcoxon rank sum tests were used.

Results and limitations

All robotic procedures were successful, all surgical margins were negative, and no kidneys were lost. Compared with group 2 tumors, group 1 tumors were larger (3.4 vs 2.6 cm, p = 0.004), more commonly hilar (24% vs 6%, p = 0.009), and more complex (PADUA 10 vs 8, p = 0.009). Group 1 patients had longer median operative time (p < 0.001) and transfusion rates (24% vs 6%, p < 0.01) but similar estimated blood loss (200 vs 150 ml), perioperative complications (15% vs 13%), and hospital stay. Group 1 patients had less decrease in estimated glomerular filtration rate at discharge (0% vs 11%, p = 0.01) and at last follow-up (11% vs 17%, p = 0.03). On computed tomography volumetrics, group 1 patients trended toward greater parenchymal preservation (95% vs 90%, p = 0.07) despite larger tumor size and volume (19 vs 8 ml, p = 0.002). Main limitations are the retrospective study design, small cohort, and short follow-up.

Conclusions

Robotic PN with superselective vascular control enables tumor excision without any global renal ischemia. Blood loss, complications, and positive margin rates were low and similar to main artery clamping. In this initial developmental phase, limitations included more perioperative transfusions and longer operative time. The advantage of superselective clamping for better renal function preservation requires validation by prospective randomized studies.

Patient summary

Preserving global blood flow to the kidney during robotic partial nephrectomy (PN) does not lead to a higher complication rate and may lead to better postoperative renal function compared with clamped PN techniques.     

Renal Pelvic Anatomy Is Associated with Incidence,Grade, and Need for Intervention for Urine Leak Following Partial Nephrectomy

Background

Although the effect of tumor complexity on perioperative outcome measures is well established, the impact of renal pelvic anatomy on perioperative outcomes remains poorly defined.

Objective

To evaluate renal pelvic anatomy as an independent predictor of urine leak in moderate- and high-complexity tumors undergoing nephron-sparing surgery.

Design, setting, and participants

Patients undergoing open partial nephrectomy (PN) for localized RCC were stratified into intermediate- and high-complexity groups using a nephrometry score (7–9 and 10–12, respectively). A renal pelvic score (RPS) was defined by the percentage of renal pelvis contained inside the volume of the renal parenchyma. On this basis, patients were categorized as having an intraparenchymal (>50%) or extraparenchymal (<50%) renal pelvis.

Outcome measurements and statistical analysis

Characteristics of patients with and without an intraparenchymal renal pelvic anatomy were compared.

Results and limitations

Inclusion criteria were met by 255 patients undergoing PN for intermediate (73.6%) and complex (26.4%) localized renal tumors (mean size: 4.6 ± 2.9 cm). Twenty-four (9.6%) renal pelves were classified as completely intraparenchymal. Following stratification by RPS, groups differed with respect to Charlson comorbidity index, body mass index, and largest tumor size, while no differences were observed between hospital length of stay, nephrometry score, estimated blood loss, operative time, and age. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (75% vs 6.5%; p = 0.001), secondary intervention (37.5% vs 3.9%; p < 0.001), and prolonged duration of urine leak (93 ± 62 d vs 56 ± 29 d; p = 0.025).

Conclusions

Intraparenchymal renal pelvic anatomy is an uncommon anatomic variant associated with an increased rate of urine leak following PN. Elevated pressures within a small intraparenchymal renal pelvis might explain the increased risk. Preoperative imaging characteristics suggestive of increased risk for urine leak should be considered in perioperative management algorithms.     

Intravenous arginine and human skin graft donor site healing: a randomized controlled trial

Background and aims

Studies evaluating the effect of arginine supplementation in human wound healing are inhomogeneous with conflicting results. This study aims to clarify the role of arginine supplementation in the healing of human skin graft donor sites.

Methods

35 subjects undergoing skin autografting were randomly assigned to receive intravenous arginine (n = 16) or placebo (n = 19) for 5 days in a dose of 30 g of arginine or an isovolumetric amount of placebo (25.2 g of alanine). Wound healing was evaluated at the donor sites by objectifying angiogenesis, reepithelialization and neutrophil influx. Plasma amino acid concentrations were measured to evaluate our intervention.

Results

The two groups were comparable in age, morbidity and nutritional, metabolic and inflammatory state. Plasma arginine and alanine levels increased significantly upon supplementation in the two groups, respectively. No differences were found between the arginine supplementation group and the placebo group in the studied parameters. Placebo vs. arginine; mean ± SD: neutrophil influx on day 2: 6.67 ± 3.0 vs. 6.57 ± 3.3, p = 0.66; angiogenesis on day 10: 8.0 ± 2.8 vs. 8.9 ± 3.1; reepithelialization in % on day 10: 81 ± 8.5 vs. 85 ± 7.1.

Conclusion

Intravenous arginine supplementation does not improve angiogenesis, reepithelialization or neutrophil influx in healing of human skin graft donor sites.     

Management of ongoing arterial haemorrhage after damage control laparotomy: Optimal timing and efficacy of transarterial embolisation

Introduction

Patients undergoing damage control laparotomy need intensive and aggressive resuscitation, and may also require adjunctive transarterial embolisation (TAE) for ongoing arterial haemorrhage. We evaluated the effectiveness and timing of TAE in these patients as well as their final outcome.

Materials and methods

From January 1998 to December 2006, the case records of 16 patients with ongoing arterial haemorrhages (hepatic haemorrhage = 7, extra-hepatic haemorrhage = 9) who underwent TAE after damage control laparotomy were reviewed. Fourteen patients had blunt injuries and two had penetrating injuries.

Results

There were 13 men and three women. Their ages ranged from 3 to 85 years (mean, 36 years). Of seven hepatic angiograms, contrast extravasation at the right hepatic artery and left hepatic artery was found in three patients each. Bilateral hepatic artery injuries were found in one patient. Of nine extra-hepatic angiograms, the internal iliac artery was the most commonly injured artery (n = 6). After TAE, 14 of 16 ongoing arterial haemorrhages could be controlled and eight patients survived; however, two patients with uncontrolled haemorrhages eventually died (hepatic artery injury = 1, lumbar artery injury = 1). Of 16 patients overall, profound haemorrhagic shock (n = 4) and multiple organ failure (n = 4) resulted in eight deaths (hepatic injury = 4, extra-hepatic injury = 4), and accounted for a mortality rate of 50%. Of 16 patients, nine were taken directly from the operating room to the angiography suite and the mortality rate was 33.3%. The other seven patients were taken to the angiography suite from the intensive care unit and the mortality rate was 71.4%. Of three survivors who underwent hepatic TAE, the operative time ranged from 30 min to 72 min (mean, 48 min). However, of four nonsurvivors who underwent hepatic TAE, the operative time ranged from 58 min to 180 min (mean, 119 min).

Conclusions

TAE is an effective tool in the management of ongoing arterial haemorrhage after damage control laparotomy and eight (50%) patients with ongoing arterial haemorrhages survived from this multidisciplinary treatment. To achieve a good outcome, the operative time of damage control laparotomy should be as short as possible and TAE should be performed without delay. Interventional radiology colleagues should be informed in advance during laparotomy and resuscitation continued in the angiography suite.     

Warm and tepid cardioplegia: Do they provide equal myocardial protection?

Background

Cardiac troponin I (CTnI) has been shown to be a marker of myocardial injury. The aim of this prospective, randomized study was to compare intermittent antegrade warm cardioplegia with tepid blood cardioplegia in patients undergoing first elective coronary artery bypass graft, using CTnI release as the criterion for evaluating the adequacy of myocardial protection.

Methods

Seventy patients were randomly assigned to one of two cardioplegia groups. CTnI concentrations were measured in serial venous blood samples drawn immediately before cardiopulmonary bypass and after aortic unclamping at 6, 9, 12, and 24 hours. Analysis of covariance with repeated measures was performed to test the effect of the type of cardioplegia and time on CTnI concentration.

Results

The total amount of CTnI released (8.23 ± 20.5 μg in the warm group and 3.19 ± 2.4 μg in the tepid group) was not statistically different (p = 0.23). The CTnI concentration did not differ for any sample in either of the two groups when adjusted on ejection fraction and the number of preoperative myocardial infarctions (p = 0.06). No patient in the tepid group versus 4 patients in the warm group showed CTnI evidence of perioperative myocardial infarction (p = 0.12).

Conclusions

Our study showed no preference for warm or tepid cardioplegia in terms of myocardial protection, either for clinical or biological data.