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Choi M, Lee JH, Roh YH, Kim H, Jang JY, Choi SH, Kang CM. Multidimensional Nomogram to Predict Postoperative Pancreatic Fistula after Minimally Invasive Pancreaticoduodenectomy. Ann Surg Oncol 2023; 30:5083-5090. [PMID: 37195514 DOI: 10.1245/s10434-023-13360-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 03/01/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is an inherently severe risk of pancreatic resection. Previous research has proposed models that identify risk factors and predict CR-POPF, although these are rarely applicable to minimally invasive pancreaticoduodenectomy (MIPD). This study aimed to evaluate the individual risks of CR-POPF and to propose a nomogram for predicting POPF in MIPD. PATIENTS AND METHODS We retrospectively reviewed the medical records of 429 patients who underwent MIPD. In the multivariate analysis, the Akaike information criterion stepwise logistic regression method was used to select the final model to develop the nomogram. RESULTS Of 429 patients, 53 (12.4%) experienced CR-POPF. On multivariate analysis, pancreatic texture (p = 0.001), open conversion (p = 0.008), intraoperative transfusion (p = 0.011), and pathology (p = 0.048) were identified as independent predictors of CR-POPF. The nomogram was developed based on patient, pancreatic, operative, and surgeon factors by using the following four additional clinical factors as variables: American Society of Anesthesiologists class ≥ III, size of pancreatic duct, type of surgical approach, and < 40 cases of MIPD experience. CONCLUSIONS A multidimensional nomogram was developed to predict CR-POPF after MIPD. This nomogram and calculator can help surgeons anticipate, select, and manage critical complications.
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Affiliation(s)
- Munseok Choi
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, South Korea
| | - Jae Hoon Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yun Ho Roh
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyeyeon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Young Jang
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Sung Hoon Choi
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
| | - Chang Moo Kang
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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Dhiman P, Ma J, Gibbs VN, Rampotas A, Kamal H, Arshad SS, Kirtley S, Doree C, Murphy MF, Collins GS, Palmer AJR. Systematic review highlights high risk of bias of clinical prediction models for blood transfusion in patients undergoing elective surgery. J Clin Epidemiol 2023; 159:10-30. [PMID: 37156342 DOI: 10.1016/j.jclinepi.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/21/2023] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Blood transfusion can be a lifesaving intervention after perioperative blood loss. Many prediction models have been developed to identify patients most likely to require blood transfusion during elective surgery, but it is unclear whether any are suitable for clinical practice. STUDY DESIGN AND SETTING We conducted a systematic review, searching MEDLINE, Embase, PubMed, The Cochrane Library, Transfusion Evidence Library, Scopus, and Web of Science databases for studies reporting the development or validation of a blood transfusion prediction model in elective surgery patients between January 1, 2000 and June 30, 2021. We extracted study characteristics, discrimination performance (c-statistics) of final models, and data, which we used to perform risk of bias assessment using the Prediction model risk of bias assessment tool (PROBAST). RESULTS We reviewed 66 studies (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes. CONCLUSION Most blood transfusion prediction models are at high risk of bias and suffer from poor reporting and methodological quality, which must be addressed before they can be safely used in clinical practice.
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Affiliation(s)
- Paula Dhiman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Jie Ma
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Victoria N Gibbs
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alexandros Rampotas
- Systematic Review Initiative, NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
| | - Hassan Kamal
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; School of Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland DD1 9SY
| | - Sahar S Arshad
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
| | - Michael F Murphy
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Systematic Review Initiative, NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK; NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK; NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford University Hospitals, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE, UK
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Jackson T, Vedantam S, Bradshaw R, Cho E, Lim J, Nagatomo K, Osman H, Jeyarajah DR. Unrecognized anemia after whipple - should we learn from gastric bypass? Expert Rev Gastroenterol Hepatol 2020; 14:1119-1123. [PMID: 32772584 DOI: 10.1080/17474124.2020.1808459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Several pathophysiologic changes after the Whipple procedure have been well described, but anemia has not. Post-surgical changes can impede micronutrient absorption. We hypothesize that patients post-pancreatoduodenectomy suffer from iron deficiency anemia. METHODS Patients who underwent a pancreatoduodenectomy from 2016 to 2018 were retrospectively evaluated. Preoperative, intraoperative, and postoperative data, including hemoglobin (Hb) levels and mean corpuscular volume (MCV) as well as therapies with chemoradiation, iron, and/or B12 were collected at 1-, 3-, 6-, and 12-months after surgery. RESULTS The dataset included 74 patients (median age: 64 years). Mean preoperative Hb and MCV were 11.7 ± 1.9 g/dl and 90.1 ± 7.3 fl, respectively. Significant changes in Hb were noted at 1 and 6 months (11.7 vs 10.9, p = 0.01 and 11.7 vs 11.3, p = 0.003, respectively), and in MCV were noted at 6 and 12 months (90.1 vs 94.6, p = 0.008 and 90.1 vs. 93.7, p = 0.02, respectively). CONCLUSIONS All patients remained anemic after pancreatoduodenectomy. This was not linked to chemotherapy. Iron and vitamin B12 supplementation, given in a minority, did not ameliorate the anemia. Future studies should investigate this lack of aid, as nutrient supplementation may be an important change in the standard of care of these patients.
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Affiliation(s)
| | - Shyam Vedantam
- University of North Texas Health Science Center-Texas College of Osteopathic Medicine, Fort Worth, Texas
| | | | - Edward Cho
- Richardson Methodist Medical Center, Richardson, Texas
| | - Joseph Lim
- University of North Texas Health Science Center-Texas College of Osteopathic Medicine, Fort Worth, Texas
| | - Kei Nagatomo
- Richardson Methodist Medical Center, Richardson, Texas
| | - Houssam Osman
- Richardson Methodist Medical Center, Richardson, Texas
| | - D Rohan Jeyarajah
- Richardson Methodist Medical Center, Richardson, Texas.,University of North Texas Health Science Center-Texas College of Osteopathic Medicine, Fort Worth, Texas
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Zwiep TM, Gilbert RWD, Moloo H, Touchie D, Martel G, Wallace T, Bertens KA. Improving the treatment of pre-operative anemia in hepato-pancreato-biliary patients: a quality improvement initiative. Patient Saf Surg 2020; 14:18. [PMID: 32346397 PMCID: PMC7181477 DOI: 10.1186/s13037-020-00239-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022] Open
Abstract
Background Pre-operative anemia is a common, but treatable, condition encountered by surgical patients. It has been associated with increased perioperative complications, length of stay, and blood transfusions. The aim of this project was to increase the treatment rate of pre-operative anemia to 75% of patients consented for major hepato-pancreato-biliary (HPB) surgery. Methods This was an interrupted time series study and a spread initiative from a similar project in a colorectal surgery population. Interventions included an anemia screening and treatment algorithm, standardized blood work, referral to a patient blood management program, and standardized oral iron prescriptions. The primary outcome measure was the change in pre-operative anemia treatment rate and the secondary outcome measure was the post treatment increase in hemoglobin. Results A total of 208 patients were included (n = 124 pre-intervention and n = 84 post-intervention). Anemia was present in 39.9% of patients. The treatment rate of pre-operative anemia increased to 44.1% from 28.6%. The mean hemoglobin increased from 110 g/L to 119 g/L in patients who were treated (p = 0.03). There was no significant increase or decrease in blood transfusions or mean number of red cell units transfused per patient. Screening rates for pre-operative anemia increased from 41.1 to 64.3% and appropriate referrals to the patient blood management program increased from 14.3 to 67.6%. Conclusions This study demonstrates a small scale spread initiative focused on the treatment of pre-operative anemia. Although the goal to treat 75% of anemic patients was not reached, an effective referral pathway to an existing patient blood management program was developed, and a significant increase in the mean hemoglobin in anemic patients who have been treated pre-operatively was demonstrated.
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Affiliation(s)
- Terry M Zwiep
- 1Department of Surgery, London Health Sciences Centre, London, Canada
| | - Richard W D Gilbert
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Husein Moloo
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Donna Touchie
- 3Surgical Blood Management Program, The Ottawa Hospital, Ottawa, Canada
| | - Guillaume Martel
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Tom Wallace
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Kimberly A Bertens
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
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Perioperative blood transfusion is associated with an increased risk for post-surgical infection following pancreaticoduodenectomy. HPB (Oxford) 2019; 21:1577-1584. [PMID: 31040065 DOI: 10.1016/j.hpb.2019.03.374] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/16/2018] [Accepted: 03/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE Perioperative blood transfusion is common after pancreaticoduodenectomy (PD) and may predispose patients to infectious complications. The purpose of this study is to examine the association between perioperative blood transfusion and the development of post-surgical infection after PD. METHODS Patients who underwent PD from 2014 to 2015 were identified in the NSQIP pancreas-specific database. Logistic regression analysis was used to compute adjusted odds ratios (aOR) to identify an independent association between perioperative red blood cell transfusion (within 72 h of surgery) and the development of post-operative infection after 72 h. RESULTS A total of 6869 patients underwent PD during this time period. Of these, 1372 (20.0%) patients received a perioperative blood transfusion. Patients receiving transfusion had a higher rate of post-operative infection (34.7% vs 26.5%, p < 0.001). After adjusting for significant covariates, perioperative transfusion was independently associated the subsequent development of any post-operative infection (aOR 1.41 [1.23-1.62], p < 0.001), including pneumonia (aOR 2.01 [1.48-2.74], p < 0.001), sepsis (aOR 1.62 [1.29-2.04], p < 0.001), and septic shock (aOR 1.92 [1.38-2.68], p < 0.001). CONCLUSION There is a strong independent association between perioperative blood transfusion and the development of subsequent post-operative infection following PD.
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Howell EP, Kildow BJ, Karas V, Green CL, Cunningham DJ, Ryan SP, Bolognesi MP, Seyler TM. Clinical Impact of Routine Complete Blood Counts Following Total Knee Arthroplasty. J Arthroplasty 2019; 34:S168-S172. [PMID: 30948289 DOI: 10.1016/j.arth.2019.03.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Routine laboratory studies are generally obtained following total knee arthroplasty (TKA), and often continued daily until discharge. This study aims to investigate the utility and cost-effectiveness of complete blood count (CBC) tests following TKA. METHODS Retrospective review identified 484 patients who underwent primary TKA under a tourniquet at a single institution. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were calculated for all variables. RESULTS Twenty-five patients required transfusion following TKA (5.2%). Patients requiring transfusion had significantly lower preoperative hemoglobin compared to patients who did not require transfusion (11.47 vs 13.58 g/dL, P = .005). Risk of transfusion was 5.2 times higher in patients with preoperative anemia (95% confidence interval 2.90-9.35, P < .001). Without TXA, patients were 2.75 times more likely to receive transfusion (95% confidence interval 1.43-5.30, P < .001). An average of 2.9 CBC tests were collected per patient who did not receive medical intervention, costing a total of $144,773.80 in associated hospital charges ($316.10 per patient). CONCLUSION Ensuring quality, cost-effective patient care following total joint arthroplasty is essential in the era of bundled payments. Routine postoperative CBCs do not add value for patients with normal preoperative hemoglobin who receive TXA during TKA performed under tourniquet. Patients who are anemic preoperatively or do not receive TXA should obtain a postoperative CBC test. Daily CBCs are unnecessary if the first postoperative CBC does not prompt intervention.
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Affiliation(s)
- Elizabeth P Howell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Beau J Kildow
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Vasili Karas
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Cynthia L Green
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
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