Impact of Delta Hemoglobin on Provider Transfusion Practices and Post-operative Morbidity Among Patients Undergoing Liver and Pancreatic Surgery

Background

Delta hemoglobin (ΔHb) is defined as the difference between the preoperative Hb and the lowest post-operative Hb level. We sought to define the impact of ΔHb relative to nadir Hb levels on the likelihood of transfusion, as well as characterize the impact of ΔHb and nadir Hb on morbidity among a large cohort of patients undergoing complex hepatopancreatobiliary (HPB) surgery.

Methods

Patients who underwent pancreatic or hepatic resection between January 1, 2009 and June 30, 2015 at Johns Hopkins Hospital were identified. Data on the perioperative ΔHb, nadir Hb, as well as blood utilization were obtained and analyzed. Multivariable logistic regression models were used to identify the factors associated with ΔHb and the impact of ΔHb on perioperative morbidity. A Bayesian model was used to evaluate the correlation of ΔHb and nadir Hb with the likelihood of transfusion, as well as the impact on morbidity.

Results

A total of 4363 patients who underwent hepatobiliary (n?=?2200, 50.4 %) or pancreatic (n?=?2163, 49.6 %) surgery were identified. More than one quarter of patients received at least one unit of packed red blood cells (PRBC) (n?=?1187, 27.2 %). The median nadir Hb was 9.2 (IQR 7.9–10.5)?g/dL resulting in an average ΔHb of 3.4 mg/dL (IQR 2.2–4.7) corresponding to 26.3 %. Both ΔHb and nadir Hb strongly influenced provider behavior with regards to use of transfusion. Among patients with the same nadir Hb, ΔHb was strongly associated with use of transfusion; among patients who had a nadir Hb ≤6 g/dL, the use of transfusion was only 17.9 % when the ΔHb?=?10 % versus 49.1 and 80.9 % when the ΔHb was 30 or 50 %, respectively. Perioperative complications occurred in 584 patients (13.4 %) and were more common among patients with a higher value of ΔHb, as well as patients who received PRBC (both P?<?0.001).

Conclusions

The combination of the Hb trigger with ΔHb was associated with transfusion practices among providers. Larger ΔHb values, as well as receipt of transfusion, were strongly associated with risk of perioperative complication following HPB surgery.

     

Microendoscopic discectomy versus open discectomy for lumbar disc herniation: a meta-analysis

Purpose

To compare the outcomes of microendoscopic discectomy and open discectomy for patients with lumbar disc herniation.

Methods

An extensive search of studies was performed in PubMed, Medline, Embase, Cochrane library and Google Scholar. The following outcome measures were extracted: visual analogue scale (VAS), Oswestry disability index (ODI), complication, operation time, blood loss and length of hospital stay. Data analysis was conducted with RevMan 5.0.

Results

Five randomized controlled trials involving 501 patients were included in this meta-analysis. The pooled analysis showed that there was no significant difference in the VAS, ODI or complication between the two groups. However, compared with the open discectomy, the microendoscopic discectomy was associated with less blood loss [WMD = ?151.01 (?288.22, ?13.80), P = 0.03], shorter length of hospital stay [WMD = ?69.33 (?110.39, ?28.28), P = 0.0009], and longer operation time [WMD = 18.80 (7.83, 29.76), P = 0.0008].

Conclusions

Microendoscopic discectomy, which requires a demanding learning curve, may be a safe and effective alternative to conventional open discectomy for patients with lumbar disc herniation.

     

经皮血管腔内成形术结合局部小剂量持续灌注溶栓治疗糖尿病膝下动脉病变

目的 探讨采用经皮血管腔内成形术(PTA)治疗糖尿病膝下动脉病变的效果以及术后小剂量溶栓对膝下动脉血流的影响.方法 回顾性分析自2011年1月至2013年9月行介入治疗的糖尿病膝下动脉病变患者28例,共37条肢体(左下肢16条、右下肢21条),74支膝下动脉存在狭窄或闭塞,胫前动脉30支、胫后动脉22支、腓动脉22支,合并有髂股动脉病变肢体30条.根据术前CTA结果分别采用同侧顺行、经对侧股动脉入路、经肱动脉途径行PTA或支架治疗,测量介入治疗前后踝肱指数(ABI).介入治疗术后从留置导管鞘内持续经微量泵注入尿激酶(20～ 30)万U/24 h,共48 h进行溶栓,记录溶栓前后从胫骨平台到足踝处的图像帧数.术后随访3个月以上,测量ABI并行彩超或CTA检查,计量资料采用配对样本t检验.结果 32条肢体通过球囊扩张或支架得以开通,开通率为86.4％.37条肢体ABI术前为0.70±0.31,术后首日增加至0.90±0.21,差异有统计学意义(t=10.734,P＜0.05).成功开通的32条肢体在小剂量溶栓后造影,从胫骨平台到足踝处的图像帧数由介入术后即刻的(6.3±1.6)帧降低到(4.7±1.4)帧,差异有统计学意义(t=12.136,P＜0.05).6条有静息痛的肢体术后临床症状缓解明显.14条有溃疡和(或)坏疽的肢体,l例介入开通血管后从踝关节平面截肢、3例截趾,3例足趾坏疽的患者随访期间足趾自行离断而愈合,其余患者创面在1～3个月内愈合.术后随访3～ 24个月有3例患者3条肢体复发并再次行PTA治疗.结论 介入治疗糖尿病膝下动脉病变,近期疗效确切,安全性较高;介入术后小剂量溶栓治疗安全,有助于改善膝下动脉血流.     

腹腔镜胆囊切除术中超声刀和高频电刀对患者血浆CRP水平的影响

目的探讨腹腔镜胆囊切除术(LC)术中使用超声刀与高频电刀对患者血浆C-反应蛋白(CRP)水平的影响。方法选取60例择期行LC患者按奇、偶数的方法随机分为超声刀(A)组和高频电刀(B)组,每组30例,观察两组患者术前及术后第1天体温、脉搏、血常规及C-反应蛋白的变化情况。结果两组患者术后第1天体温、脉搏与术前比较差异均无统计学意义(P>0.05),但血常规及血浆C-反应蛋白水平与术前比较均明显增高(P<0.05),且B组患者术后血浆C-反应蛋白水平明显高于A组,两组比较有统计学差异(P<0.05)。结论腹腔镜胆囊切除术时使用超声刀较电刀对机体血浆C-反应蛋白水平的影响较小,若有条件可优先使用。     

宫颈癌后装放疗时膀胱直肠小肠受照剂量探讨

目的 探讨宫颈癌腔内放疗时不同体积的膀胱、直肠与危及器官受照剂量的关系。方法 选取宫颈癌患者共47例,给予剂量点处方剂量600 cGy的高剂量率腔内后装治疗,用剂量体积直方图(DVH)评价标准计划下不同体积的膀胱、直肠和小肠对相应受照剂量的影响。将膀胱按体积大小分成<80 cm³组、80~120 cm³组和>120 cm³组,直肠按体积大小分成>60 cm³ 组和≤60 cm³组,分析其体积与剂量分布的关系。采用方差分析和t检验方法分析D_{1 cm³}、D_{2 cm³}、D_30%和D_50%。结果 与膀胱体积<80 cm³组相比,80~120 cm³组和>120 cm³组的膀胱D_30%、D_50%受照剂量增高(F=5.074、5.088,P<0.05),小肠D_{1 cm³}和D_{2 cm³}值差异无统计学意义(P>0.05);与直肠体积>60 cm³ 组相比,≤60 cm³组的直肠D_{1 cm³}受照剂量减小(t=-2.045,P<0.05)。结论 宫颈癌近距离放疗时,保持膀胱的适当充盈,直肠体积的减少,可使直肠、膀胱和小肠的受照射剂量均相对降低,从而减少放疗的不良反应。     

腰椎爆裂骨折中创伤性马尾神经硬膜疝的发生及治疗

目的 探讨腰椎爆裂骨折手术中马尾神经硬膜疝的发生与治疗方法. 方法 回顾性分析2008年6月1日-2011年6月1日收治的416例腰椎爆裂骨折患者,行前路或后路椎管减压手术.收集患者一般资料、致伤机制、影像学检查、手术方法、术后疗效和随访数据,观察马尾神经硬膜疝发生情况. 结果 416例患者均成功完成手术,其中49例(11.8％)术中探查发现合并马尾神经硬膜疝.前路手术组115例患者,马尾神经硬膜疝发生率7.8％(9/115).后路手术组301例患者,马尾神经硬膜疝发生率为(13.3％,40/301),其中40例腰椎爆裂骨折伴椎板骨折患者中有38例合并马尾神经硬膜疝,发生率为95％.发生马尾神经硬膜疝的患者中44例(90％)表现为神经功能障碍,5例(10％)虽然神经功能完好,但在术中发现很大一部分马尾神经根被嵌夹在椎板骨折裂隙中. 结论 对于伴有神经功能障碍及椎板骨折的腰椎爆裂骨折患者,应考虑创伤性马尾神经硬膜疝存在的可能,术中应谨慎操作以防止神经损伤进一步加重.     

胆囊颈部结石嵌顿的腹腔镜治疗

目的评价研究腹腔镜胆囊切除术（LC）在处理胆囊管结石嵌顿的措施。方法回顾分析2003年1月-2008年12月32例胆囊颈部结石并嵌顿行腹腔镜胆囊切除术病例,总结处理胆囊结石嵌顿的对策和技巧。结果29例成功,中转开腹3例,胆囊三角“胼胝样”粘连2例,Mirrizzi综合征1例。中转开腹行胆囊切除＋腹腔引流术;无严重并发症发生。结论对胆囊颈部结石嵌顿发病在48h内、胆囊周围粘连不致密、Calot三角易解剖者可行Lc。     

盐酸阿扑吗啡舌下片治疗勃起功能障碍的安全性和有效性研究

目的 探索盐酸阿扑吗啡舌下片治疗男性勃起功能障碍(ED)的安全性和有效性.方法 采用多中心、随机、双盲、安慰剂对照研究方法,在国内7家医院对盐酸阿扑吗啡舌下片2mg或3 mg和安慰剂的238例ED病人进行临床观察.结果 3个主要疗效指标的统计学分析显示,试验药物组疗效优于安慰剂组.次要疗效指标分析结果与主要疗效指标一致.与药物相关的主要不良事件有头晕、恶心、面部潮红、出汗、胃部不适和呕吐,严重程度为轻至中度,呈一过性,无需处理.结论 盐酸阿扑吗啡舌下片2 mg或3 mg治疗国人ED足安全和有效的.     

Endoscopic decompression of the optic canal for traumatic optic neuropathy

Purpose: Traumatic optic neuropathy (TON) is a serious complication of head trauma with the incidence rate of 0.5%e5%. The aim of this study was to investigate the therapeutic efficacy of endoscopic decompression of the optic canal for optic nerve injuries. Methods: In this study, 11 patients treated in our hospital from January 2009 to January 2015 with the visual loss resulting from TON were retrospectively reviewed for preoperative vision, visual evoked potential (VEP) scan, surgical approach, postoperative visual acuity, complications, and follow-up results. Results: All these patients received endoscopic decompression of the optic canal. At the 3-month followup, the visual acuity improvement rate of the 11 patients was 45.5%. The vision acuity of 2 cases improved from hand movement to 0.08 and 0.3 after operation. Another patient''s vision acuity returned to 0.05 compared to light sensation preoperatively. Two cases had finger counting before surgery but they had a vision acuity of 0.4 and light sensation respectively after surgery. However, the other 6 cases'' vision did not improve after surgery. Conclusion: Endoscopic decompression of the optic canal is an effective way to cure TON. VEP could be used as an important reference for preoperative and prognosis evaluation. Operative time after trauma is only a relative condition that may affect the therapeutic effect of optic canal decompression. Poor results of this procedure may be related to the severity of the optic nerve injury.