How to approach major surgery where patients refuse blood transfusion (including Jehovah's Witnesses)

Jehovah's Witnesses do not permit the use of allogeneic blood products. An increasing number of patients are refusing blood transfusion for non-religious reasons. In addition, blood stores are decreasing, and costs are increasing. Transfusion avoidance strategies are, therefore, desirable. Bloodless surgery refers to the co-ordinated peri-operative care of patients aiming to avoid blood transfusion, and improve patient outcomes. These principles are likely to gain popularity, and become standard practice for all patients. This review offers a practical approach to the surgical management of Jehovah's Witnesses, and an introduction to the principles of bloodless surgery that can be applied to the management of all patients.     

Cystic undifferentiated sarcoma of liver in children: a pitfall diagnosis in endemic hydatidosis areas

Undifferentiated (embryonal) sarcoma (UES) of the liver is a very rare pediatric neoplasm with an aggressive behavior. Multimodal treatment including complete surgical resection and chemotherapy has improved survival.We report a case of UES occurring in a 15-year-old female. Radiographic findings showed a multicystic mass appearance. The diagnosis of hydatid cyst was initially presumed. A complete tumor resection after 3 cycles of chemotherapy was performed. Histologically, only 20% of tumor necrosis was noted. Adjuvant chemotherapy was instituted. She remained well at 11 months of follow-up.Cystic appearance is a usual finding in UES. Differential diagnosis with hydatid cyst may be problematic in endemic hydatidosis areas.     

The suprahepatic approach. An easy laparoscopic access to the hiatus in obese patients

The conventional laparoscopic access to the gastroesophageal junction involves the retraction the left hepatic lobe upward. This approach could be particularly difficult in obese patients because of a huge fatty liver. The technique described here aims to overcome this difficulty be using a suprahepatic route by displacing the left lobe downward after dividing the left triangular ligament. This approach allows a good exposure of the gastroesophageal junction to perform a fundoplication or a gastric banding.     

Endoscopic versus open component separation in complex abdominal wall reconstruction

Background

Open component separation has a high wound complication rate. Newer endoscopic approaches are described with no comparative trials.

Methods

A retrospective review (2005-2009) of patients undergoing open or endoscopic component separation was performed.

Results

Forty-four cases were identified (22 endoscopic; 22 open). All perioperative variables were the same except age (65 open vs 55 endoscopic; P < .05). Hospital length of stay was 11 days in the open group versus 8 days in the endoscopic group (P = .09). Wound complications were 52% in the open group versus 27% in the endoscopic group (P = .09). Wound-related interventions occurred in 45% of the open group and 33% of the endoscopic group. Hernia recurrences rates were similar (open, 32%; endoscopic, 27%; P = .99).

Conclusions

Open and endoscopic components separation have similar rates of recurrence. The endoscopic group had shorter lengths of stay and less major wound complications. The endoscopic approach may be the ideal technique for complex abdominal wall reconstruction.     

Inflammatory biomarkers at hospital discharge are associated with readmission and death in patients hospitalized for COVID-19

European Journal of Clinical Microbiology & Infectious Diseases -     

Systematic Review and Meta-analysis of Enhanced Recovery After Pancreatic Surgery with Particular Emphasis on Pancreaticoduodenectomies

Background

In the past decade, Enhanced Recovery after Surgery (ERAS) protocols have been implemented in several fields of surgery. With these protocols, a faster recovery and shorter hospital stay can be accomplished without an increase in morbidity or mortality. The purpose of this study was to review systematically the evidence for implementation of an ERAS protocol in pancreatic resections, with particular emphasis on pancreaticoduodenectomies (PDs).

Methods

A systematic search was performed in Medline, Embase, Pubmed, CINAHL, and the Cochrane library for papers describing an ERAS program in adult patients undergoing elective pancreatic surgery published between January 1966 and December 2012. The primary outcome measure was postoperative length of stay. Secondary outcome measures were time to recovery of normal function, overall postoperative complication rates, readmissions, and mortality. Subsequently, a meta-analysis of outcome measures focusing on PD was conducted. This systematic review and meta-analysis was performed according to the PRISMA statement.

Results

The literature search produced 248 potentially relevant papers. Of these, eight papers met the predefined inclusion criteria: five case-control studies, two retrospective studies, and one prospective study, describing a total of 1,558 patients. Only three of the studies reported data on discharge criteria and assessed time to recovery and return to normal function. Implementation of an ERAS protocol led in four of five comparative studies to a significant decrease in length of stay (reduction of 2–6 days in different studies). Meta-analysis of four studies focusing on PDs showed that there was a significant difference in complication rates in favor of the ERAS group (absolute risk difference 8.2 %, 95 % confidence interval (CI) 2.0–14.4, p = 0.008). Introduction of an ERAS protocol did not result in an increase in mortality or readmissions. Delayed gastric emptying and incidence of pancreatic fistula did not differ significantly between groups. All studies reporting on hospital costs showed a decrease after implementation of ERAS.

Conclusions

This systematic review suggests that using an ERAS protocol in pancreatic resections may help to shorten hospital length of stay without compromising morbidity and mortality. This seemed to apply to distal pancreatectomy, total pancreatectomy, and PD. Meta-analysis was performed for those studies focusing on PD and showed that there were no differences in readmission or mortality. Morbidity rates were significantly lower for patients managed according ERAS principles.     

The significance of combining World Health Organization and Center for Disease Control criteria to resolve indeterminate human immunodeficiency virus type-1 Western blot results

A total of 466 repeatedly reactive HIV-1 blood samples evidenced by enzyme immunoassay were analyzed by the Western blot method and interpreted according to WHO and CDC criteria. Discordant and indeterminate samples were further analyzed by PCR. When the Western blot result was classified as indeterminate, according to both WHO and CDC criteria, the PCR test was always negative. These findings suggest that samples with double-indeterminate status should be reported as negative.     

Use of combined detection of hepatitis C virus core antigen and antibodies to reduce the serological window-phase

OBJECTIVES: In this study, we aimed at evaluating the performances of a combined assay for the detection of hepatitis C virus core antigen and antibodies and comparing this test with conventional third generation Elisa. MATERIAL AND METHODS: Two hundred forty-one samples were included in this study and tested by Monolisa HCV Ag-Ab ULTRA, Biorad and compared to Monolisa Anti-HCV Plus. A comparative study was performed on a HCV seroconversion panel (Monolisa anti-HCV Plus, Biorad; Innotest HCV Ab IV, Innogenetics and Murex anti-HCV, Abbott). False positive samples were detected with western blot assay (INNO-LIA HCV Ab III, Innogenetics). Two anti-HCV negative haemodialysis patients with rise in ALT have been tested for RNA detection (Amplicor v2.0, Roche). RESULTS: Results obtained with Biorad Ag-Ab were in agreement with third generation ELISA on HCV seroconversion panel. From anti-HCV negative patients, four samples were found low positive with HCV Ag-Ab. Two anti-HCV negative haemodialysis patients/HCV RNA positive were also negative with HCV Ag-Ab and 13 low positive samples with Biorad Ab were found negative with Ag-Ab. CONCLUSION: The HCV Ag-Ab assay has a high specificity and sensitivity comparatively to conventional ELISA; but in our study we don't prove the reduction of the "serologic window" for detection of anti-HCV antibodies.