Effects of propofol versus sevoflurane on surgical field visibility during arthroscopic rotator cuff repair: a randomized trial

BACKGROUND

During arthroscopic rotator cuff repair (ARCR), clear surgical field visibility (SFV) is the basis of successful surgery, but the choice of anesthesia maintenance drugs may have different effects on SFV. In this study, we aimed to compare the effects of propofol- and sevoflurane-based general anesthesia on SFV in patients undergoing ARCR.

METHODS

Patients (n = 130) undergoing elective ARCR in the lateral decubitus position were randomized into either the propofol group or sevoflurane group (65 per group). The duration of surgery and increased pressure irrigation (IPI), Boezaart score, rocuronium consumption and usage of remifentanil were recorded. The time of both spontaneous respiration recovery and extubation and the incidences of postoperative nausea and vomiting and agitation were also recorded.

RESULTS

The Boezaart score, duration of IPI and ratio of the duration of IPI to the duration of surgery (IPI/S ratio) were similar between the groups (P > 0.05). Rocuronium consumption, number of patients requiring remifentanil infusion and total remifentanil consumption were significantly lower in the sevoflurane group (P < 0.05). The spontaneous respiration recovery time was significantly longer in the propofol group (P < 0.05), but there were no differences in the extubation time between the groups(P > 0.05).

CONCLUSIONS

Compared with propofol, sevoflurane provides equally clear SFV while improving the convenience of anesthesia maintenance in ARCR patients with interscalene plexus (ISB) combined with general anesthesia.

TRIAL REGISTRATION

This single-center, prospective, RCT was retrospective registered at Chinese Clinical Trial Registry with the registration number ChiCTR2300072110 (02/06/2023).

Effect of enhanced recovery after surgery with multidisciplinary collaboration on nursing outcomes after total knee arthroplasty

BACKGROUND

There is a lack of studies on the effects of enhanced recovery after surgery (ERAS) with multidisciplinary collaboration on the nursing outcomes of total knee arthroplasty (TKA).

AIM

To explore the effect of ERAS with multidisciplinary collaboration on nursing outcomes after TKA.

METHODS

We retrospectively analyzed the clinical data of 80 patients who underwent TKA at a tertiary hospital between January 2021 and December 2022. The patients were divided into two groups according to the nursing mode: the ERAS group (n = 40) received ERAS with multidisciplinary collaboration, and the conventional group (n = 40) received routine nursing. The following indicators were compared between the two groups: length of hospital stay, hospitalization cost, intraoperative blood loss, hemoglobin level 24 h after surgery, visual analog scale (VAS) score for pain, range of motion (ROM) of the knee joint, Hospital for Special Surgery (HSS) knee score, and postoperative complications.

RESULTS

The ERAS group had a significantly shorter length of hospital stay, lower hospitalization cost, less intraoperative blood loss, higher hemoglobin level 24 h after surgery, lower VAS score for pain, higher knee joint ROM, and higher HSS knee score than the conventional group (all P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P > 0.05).

CONCLUSION

Multidisciplinary collaboration with ERAS can reduce blood loss, shorten hospital stay, and improve knee function in patients undergoing TKA.

Controlled arterial hypotension during resection of cerebral arteriovenous malformations

Background

Resection of cerebral arteriovenous malformations (AVM) is technically demanding because of size, eloquent location or diffuse nidus. Controlled arterial hypotension (CAH) could facilitate haemostasis. We performed a study to characterize the duration and degree of CAH and to investigate its association with blood loss and outcome.

Methods

We retrospectively analysed intraoperative arterial blood pressure of 56 patients that underwent AVM-resection performed by the same neurosurgeon between 2003 and 2012. Degree of CAH, AVM size, grading and neurological outcome were studied. Patients were divided into two groups, depending on whether CAH was performed (hypotension group) or not (control group).

Results

The hypotension group consisted of 28 patients, which presented with riskier to treat AVMs and a higher Spetzler-Martin grading. CAH was achieved by application of urapidil, increasing anaesthetic depth or a combination thereof. Systolic and mean arterial blood pressure were lowered to 82 ± 7 and 57 ± 7 mmHg, respectively, for a median duration of 58 min [25% percentile: 26 min.; 75% percentile: 107 min]. In the hypotension group, duration of surgery (4.4 ± 1.3 h) was significantly (p <  0.001) longer, and median blood loss (500 ml) was significantly (p = 0.002) higher than in the control group (3.3 ± 0.9 h and 200 ml, respectively). No case fatalities occurred. CAH was associated with a higher amount of postoperative neurological deficits.

Conclusions

Whether CAH caused neurological deficits or prevented worse outcomes could be clarified by a prospective randomised study, which is regarded as ethically problematic in the context of bleeding. CAH should only be used after strict indication and should be applied as mild and short as possible.

[Application of tranexamic acid in the treatment of intertrochanteric fracture of femur]

OBJECTIVE

To investigate the application of tranexamic acid in the treatment of intertrochanteric fracture.

METHODS

From January 2017 to October 2019, 100 patients with intertrochanteric fracture were randomly divided into observation group (48 cases) and control group(52 cases). All patients received the same surgical treatment. The control group was given tranexamic acid 20 minutes before operation, and 15 mg/kg diluted in 250 ml sodium chloride injection, intravenous drip;the observation group was given tranexamic acid 0.5 g dissolved in 20 ml normal saline injected into femoral bone marrow cavity for local treatment on the basis of the control group. The blood loss, operation time and postoperative hospital stay were compared between two groups. Hematocrit, hemoglobin, D-dimer and fibrinogen levels were analyzed before and after operation, and the incidence of thrombotic complications was observed.

RESULTS

The total blood loss, dominant blood loss, hidden blood loss and postoperative drainage volume of the observation group were significantly lower than those of the control group (P<0.05), and the postoperative hospital stay was significantly shorter than that of the control group (P<0.05). The postoperative hemoglobin and hematocrit of two groups were significantly lower than those before operation (P<0.05), while the postoperative hemoglobin and hematocrit of the observation group were significantly higher than those of the control group (P<0.05). The incidence of thrombotic complications in the observation group was 10.42%, which was not significantly different from that in the control group (11.54%)(P>0.05).

CONCLUSION

Tranexamic acid combined with systemic and local application has important clinical significance in reducing perioperative blood lossand blood cell loss in patients with intertrochanteric fracture, and has good safety.

Tranexamic acid use to decrease blood loss in primary shoulder and elbow replacement: A systematic review and meta-analysis

PURPOSE

Tranexamic acid (TXA) is an inexpensive antifibrinolytic agent that significantly reduces peri-operative blood loss and transfusion requirements after total hip and knee replacement. This meta-analysis demonstrates the effects of TXA on blood loss in total shoulder replacement (TSR) and total elbow replacement (TER).

METHODS

We systematically searched MEDLINE, EMBASE and CENTRAL from inception to September 03, 2020 for randomised controlled trial (RCTs) and observational studies. Our primary outcome was blood loss. Secondary outcomes included the need for blood transfusion, and post-operative venous thromboembolic (VTE) complications. Mean differences (MD) and relative risks with 95% confidence intervals (CIs) were reported.

RESULTS

Four RCTs and five retrospective cohort studies (RCS) met eligibility criteria for TSRs, but none for TERs. RCT data determined that TXA administration significantly decreased estimated total blood loss (MD -358mL), post-operative blood loss (MD -113mL), change in haemoglobin (Hb) (MD -0.71 g/dL) and total Hb loss (MD -35.3g) when compared to placebo. RCS data demonstrated significant association between TXA administration and decreased in post-operative blood loss, change in Hb, change in Hct and length of stay. There was no significant difference in transfusion requirements or VTE complications.

CONCLUSION

TXA administration in safe and effective in patients undergoing primary TSR: it significantly decreases blood loss compared with placebo and is associated with shorter length of stay compared with no treatment. No significant increase in VTE complications was found. TXA administration should be routinely considered for patients undergoing TSR. Further research is needed to demonstrate the treatment effect in patients undergoing TER.

[Efficacy and safety of tranexamic acid in total hip arthroplasty via direct anterior approach]

OBJECTIVE

To evaluate the efficacy and safety of local application of tranexamic acid (TXA) in reducing perioperative blood loss in total hip arthroplasty via direct anterior approach (DAA).

METHODS

From July 2013 to September 2018, 46 patients with avascular necrosis of the femoral head were divided into tranexamic acid group (n=23) and saline group (n=23). In the tranexamic acid group, there were 14 males and 9 females, aged 52 to 72(63.70±5.34) years old. They were diluted with 3 g tranexamic acid in 50 ml normal saline and immersed in the joint cavity for 3 min after prosthesis replacement;in the normal saline group, there were 13 males and 10 females, aged 55 to 73 (61.26±5.78) years, who were treated with the sameamount of normal saline. The blood loss, hemoglobin value, number of blood transfusion cases, the time of first landing after operation, the incidence of thrombosis and incision adverse events were compared between the two groups. Harris score was used to evaluate hip joint function at 1 and 3 months after operation.

RESULTS

The incision healed well and no obvious complications occurred in the two groups. All patients were followed up for 12 to 59 months(averaged 31.11 months). No hip pain was found in the follow-up patients. Hip joint function was improved effectively and no prosthesis loosening occurred. The total perioperative blood loss in tranexamic acid group and normal saline group was(740.09±77.14) ml and (1 069.07±113.53) ml respectively, 24 hours after operation, the drainage volume was (87.61±9.28) ml, (233.83±25.62) ml, the hidden blood loss was (409.65±38.01) ml and (588.33±57.16) ml. the difference of hemoglobin before and after operation was (24.78±2.19) g / L and (33.57±2.95) g / L, the difference was statistically significant (P<0.05). There was no significant difference in blood loss, incidence of deep vein thrombosis and pulmonary embolism, and Harris score of hip joint between the two groups (P>0.05).

CONCLUSION

local application of tranexamic acid in total hip arthroplasty through direct anterior approach can safely and effectively reduce perioperative blood loss, and does not increase the risk of thrombosis, and does not affect the normal recovery of joint function.

[Analysis of hemostatic effect of intra-articular injection of tranexamic acid after minimally invasive unicompartmental knee arthroplasty]

OBJECTIVE

To investigate the effect of intra-articular injection of tranexamic acid on blood loss and blood transfusion rate after minimally invasive unicompartmental knee arthroplasty.

METHODS

From January 2015 to September 2017, 90 patients underwent minimally invasive unicompartmental knee arthroplasty were divided into tranexamic acid group and control group, 45 cases in each group. In the tranexamic acid group, there were 22 males and 23 females, aged 62 to 69 (66.1±2.4) years;in the control group, 20 males and 25 females, aged 63 to 71(68.5±5.2) years. The amount of bleeding in the drainage ball at 48 hours after operation was recorded, and the blood transfusion rate and hematocrit level duringthe perioperative period were recorded. The factors influencing perioperative blood loss included gender, age and body mass index (BMI).

RESULTS

All patients were followed up for 12.5 to 28.3 (22.8±7.9) months. During the follow-up, the wounds of the two groups healed well, and no deep vein thrombosis and pulmonary embolism occurred. There was no significant difference in postoperative blood loss between the tranexamic acid group and the control group. The postoperative bleeding volume in the tranexamic acid group was (110.0±52.1) ml, and that in the control group was (123.0±64.5) ml (P=0.39). There was no blood transfusion in the two groups.

CONCLUSION

Intra articular injection of tranexamic acid can not significantly reduce the postoperative blood loss in patients with minimally invasive unicompartment.

[Effect of indwelling drainage tube and extubation time on recessive hemorrhage and functional recovery after total hip arthroplasty]

OBJECTIVE

To study and compare the effect of indwelling drainage tube and extubation time on occult hemorrhage and functional recovery after total hip arthroplasty(THA).

METHODS

From July 2017 to June 2018, 123 patients who underwent THA in our hospital for the first time were selected as the subjects of study. According to whether the drainage tube was retained or not and the time of extubation, they were divided into three groups:in group A, 41 patients (24 males, 17 females, age 53 to 77 years) did not put drainage tube after THA;in group B, 41 patients were removed 24 hours after THA, 26 males and 15 females, aged 55 to 74 years;in group C, 41 patients were removed 48 hours after THA, 25 males and 16 females, aged 52 to 75 years. The VAS score of pain 72 hours after THA, the total and recessive blood loss, the time of starting functional exercise, and the incidence of postoperative limb swelling were recorded. All the patients were followed up for one year after discharge. Harris hip score was used to evaluate the degree of hip function recovery one year after operation.

RESULTS

The occult blood loss of group A, B and C were(513.6±25.3), (521.7±33.4), (519.3±29.8) ml, respectively, with no significant difference(P>0.05). There was no significant difference in blood loss in operation among the three groups(P>0.05). In group B and C, the postoperative apparent blood loss was more than that in group A (P<0.05). There was no significant difference in VAS scores of the three groups before and 72 hours after operation (P>0.05). The time of getting out of bed in group A was shorter than that in group B and C (P<0.05), and that in group B was shorter than that in group C(P<0.05). The Harris hip score at 1 year after operationof the three groups was significantly higher than that of before operation (P<0.05). There was no significant difference in Harris hip score before and after operation among three groups (P>0.05). There was no significant difference in the incidence of complications among three groups (P>0.05).

CONCLUSION

Whether the drainage tube is left or not and the time of extubation have no significant effect on the latent blood loss and functional recovery after THA, but without drainage tube after THA can reduce the apparent blood loss, patients can get out of bed at 6 hours after THA, which is more conducive to the recovery and nursing of patients.

[Comparison of hidden blood loss between minimally invasive percutaneous locking plate fixation and intramedullary nail fixation in the treatment of tibial shaft fracture]

OBJECTIVE

To analyze and compare the hidden blood loss of minimally invasive percutaneous plate osteosynthesis(MIPPO) combined with locking plate fixation and intramedullary nail fixation in the treatment of tibial shaft fracture.

METHODS

One hundred and ninety-one cases of tibial shaft fracture treated from January 2017 to January 2019 were analyzed retrospectively. The patients were all treated with closed reduction and divided into two groups:group A (110 cases) and group B (81 cases). In group A, 78 males and 32 females were treated with MIPPO combined with locking plate. The age ranged from 19 to 74 (45.32±11.79) years old. According to AO classification, 42cases were type 42-A, 45 were type 42-B and 23 were type 42-C fractures. Group B was treated with intramedullary nail, including 65 males and 16 females, aged 19 to 84 (45.44± 14.32) years old. According to AO classification, there were 39 cases of type 42-A, 29 cases of type 42-B and 13 cases of type 42-C. The operation time, intraoperative blood loss and hidden blood loss were observed and compared between the two groups.

RESULTS

On the first day, the hidden blood loss was (155.27±47.89) ml in group A and (160.43±131.42) ml in group B, the difference was statistically significant (P<0.001);on the third day, the hidden blood loss was (102.70±94.79) ml in group A and (338.23±85.24) ml in group B, the difference was statistically significant (P<0.001). There was no significant difference between the two groups in gender, age, height, weight, fracture type and preoperative Hct (P>0.05).

CONCLUSION

In the treatment of tibial shaft fracture with intramedullary nail, there is obvious hidden blood loss, which is much higher than expected.

Bleeding properties according to surgical sites during pediatric craniotomy: a retrospective study comparing the two stages of epilepsy surgery

Background

During pediatric epilepsy surgery, due to low circulating blood volume, intraoperative bleeding can result in significant hemodynamic instability, thereby requiring meticulous hemodynamic and transfusion strategies. Knowing the source of bleeding during the procedure would allow medical staff to better prepare the perioperative protocols for these patients. We compared intraoperative bleeding between the first (involving skin to meninges) and second (involving brain parenchyma) stages of epilepsy surgery to investigate the differences between various anatomical sites.

Methods

We reviewed the electronic medical records of 102 pediatric patients < 14 years old who underwent two-stage epilepsy surgeries during January 2012–December 2016. Invasive subdural grids were placed via craniotomy during Stage 1 and the epileptogenic zone was removed during Stage 2 of the surgery. We compared the volume of intraoperative bleeding between these two surgeries and identified variables associated with bleeding using multivariate regression analysis.

Results

Both surgeries resulted in similar intraoperative bleeding (24 vs. 26 ml/kg, P = 0.835), but Stage 2 required greater volumes of blood transfusion than Stage 1 (18.4 vs. 14.8 ml/kg, P = 0.011). Massive bleeding was associated with patients < 7 years of age in Stage 1 and weighing < 18 kg in Stage 2.

Conclusions

The volume of intraoperative bleeding was similar between the two stages of pediatric epilepsy surgery and was large enough to require blood transfusions. Thus, blood loss during pediatric epilepsy surgery occurred at both anatomic sites. This indicates the necessity of early preparation for blood transfusion in both stages of pediatric epilepsy surgery.

Perioperative management of patients receiving non-vitamin K antagonist oral anticoagulants: up-to-date recommendations

Indications of non-vitamin K antagonist oral anticoagulants (NOACs), consisting of two types: direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitor (rivaroxaban, apixaban, and edoxaban), have expanded over the last few years. Accordingly, increasing number of patients presenting for surgery are being exposed to NOACs, despite the fact that NOACs are inevitably related to increased perioperative bleeding risk. This review article contains recent clinical evidence-based up-to-date recommendations to help set up a multidisciplinary management strategy to provide a safe perioperative milieu for patients receiving NOACs. In brief, despite the paucity of related clinical evidence, several key recommendations can be drawn based on the emerging clinical evidence, expert consensus, and predictable pharmacological properties of NOACs. In elective surgeries, it seems safe to perform high-bleeding risk surgeries 2 days after cessation of NOAC, regardless of the type of NOAC. Neuraxial anesthesia should be performed 3 days after cessation of NOACs. In both instances, dabigatran needs to be discontinued for an additional 1 or 2 days, depending on the decrease in renal function. NOACs do not require a preoperative heparin bridge therapy. Emergent or urgent surgeries should preferably be delayed for at least 12 h from the last NOAC intake (better if > 24 h). If surgery cannot be delayed, consider using specific reversal agents, which are idarucizumab for dabigatran and andexanet alfa for rivaroxaban, apixaban, and edoxaban. If these specific reversal agents are not available, consider using prothrombin complex concentrates.

[Effect of total knee arthroplasty under computer navigation on intraoperative blood loss and joint function recovery]

OBJECTIVE

To analyze the effect of computer navigation assisted total knee arthroplasty on intraoperative hemorrhage and postoperative joint function recovery in patients with knee osteoarthritis.

METHODS

From February 2015 to December 2017, 65 patients with knee osteoarthritis treated by traditional total knee arthroplasty were retrospectively analyzed as the control group and 65 patients with knee osteoarthritis treated by total knee arthroplasty under computer navigation as the experimental group. Before operation, all patients showed red swelling pain of knee, pain of going up and down stairs, and pain and discomfort of waist when sitting up and standing up. All patients were treated with total knee arthroplasty. The control group was treated with traditional total knee arthroplasty, and the experimental group was treated with total knee arthroplasty under the computer navigation system. The operation related conditions of the two groups were recorded and compared including the operation time and hospitalization time; the changes of hemoglobin and hematocrit of the two groups were detected and compared before and 5 days after the operation; the blood loss of the two groups and the induced flow at each time point calculated and compared after the operation, and the perioperative allogeneic blood transfusion rate and average blood transfusion volume of the patients were recorded; The joint function scale (KSS) was used to evaluate the recovery of knee joint function before the operation, 6 and 18 months after the operation respectively and to record the incidence of postoperative infection, lower extremity venous thrombosis and other complications.

RESULTS

All the patients were successfully operated and the prognosis of the wound was good. All the patients were followed up for an average of 18 months. The operation time of the experimental group was longer than that of the control group, and the hospitalization time was shorter than that of the control group (P <0.05) ; the KSS score of the two groups at each time point after operation was higher than that before operation, but the increasing range of the test group was higher than that of the control group (P<0.05) ; there was no significant difference between the two groups in the incidence of complications (P>0.05) .

CONCLUSION

Under the guidance of computer navigation, total knee arthroplasty can prolong the operation time compared with single total knee arthroplasty, but it is more conducive to reduce perioperative blood loss, reduce the rate of postoperative allogeneic blood transfusion, ideal recovery of joint function, less complications, safety and reliability.

[Effect of tranexamic acid combined flexion position of hip and knee on perioperative bleeding following unilateral total knee arthroplasty]

OBJECTIVE

To explore clinical efficacy and safety of application of tranexamic acid for two times combined with postoperative hip and knee on flexion position for reducing blood loss during total knee arthroplasty.

METHODS

From January 2015 to January 2018, 90 patients with knee osteoarthritis underwent unilateral total knee arthroplasty, including 33 males and 57 females, aged from 61 to 85 years old with an average of(72.3±6.9) years old. The patients were randomly divided into three groups according to random number table, 30 patients in each group. In group A, there were 11 males and 9 females, aged from 61 to 84 years old with an average of (71.60±6.04) years old, body mass index was (26.04±1.95) kg/m², hemoglobin was(128.57±5.98) g/L, treated by 7.5 mg/kg tranexamic acid was injected intravenously before upper tourniquet, and 7.5 mg/kg tranexamic acid after closure of incision and before loosening tourniquet, meanwhile combined with flexion position of hip for 30° to 45° and flexion position of knee for 60° for 70°. In group B, there were 10 males and 20 females aged from 61 to 85 years old with an average of (72.04±7.47) years, body mass index was (25.92±1.70) kg/m², hemoglobin was (127.58±4.37) g/L, treated by 15 mg/kg tranexamic acid injected intravenously before loosening tourniquet. In group C, there were 12 males and 18 females aged from 62 to 85 years old with an average of (73.23±7.36) years, body mass index was (26.07±1.49) kg/m², hemoglobin was (128.31±5.61) g/L, treated with the same amount of normal saline before loosening tourniquet. Intraoperative bleeding volume, postoperative drainage volume, recessive blood loss, total blood loss volume, blood transfusion cases, activated partial thromboplastin time(APTT), prothrombin time(PT), prothrombin international standardized ratio (PT-INR) and indexes of D-dimer(D-D) were compared among three groups, as well as postoperative deep venous thrombosis and pulmonary embolism were observed among three groups.

RESULTS

No incision infection occurred in all 90 patients, and all patients were followed up from 4 to 8 months with an average of 6 months without pulmonary embolism occurred. There was no statistical difference in itraoperative bleeding volume among three groups(F=0.299, P=0.742), while there were significant differences in postoperative drainage volume, recessive blood loss, and total blood loss among three groups. The number of blood transfusion were as following, 2 cases in group A, 8 cases in group B, and 16 cases in group C, there were statistically significant differences among three groups(χ² =16.01, P<0.001). There were no differences in APTT, PT, PT-INR and D-D after operation among three groups(P>0.05), and no difference in occurrence of lower limb vein thrombosis after operation.

CONCLUSIONS

The method of using tranexamic acid before upper tourniquet, after closure of incision and before loosening tourniquet-combined with the flexion position of hip and knee could effectively reduce postoperative drainage volume, recessive bleeding, total blood loss and blood transfusion cases after total knee arthroplasty, while it does not increase risk of deep vein thrombosis and pulmonary embolism.

Anterior versus posterior instrumentation for treatment of thoracolumbar tuberculosis : A meta-analysis

BACKGROUND

To compare clinical and functional outcomes of anterior versus posterior debridement and spinal fixation for surgical treatment of thoracolumbar tuberculosis.

METHODS

A computer-based online search of the Cochrane Library, PubMed, EMBase, Wanfang, VIP, and the CNKI database was performed. The methodological quality of included studies was evaluated, and data analyses were performed using RevMan 5.0 software (The Nordic Cochrane Centre, The Cochrane Collaboration Copenhagen, Denmark).

RESULTS

Eleven trials were studied, with eight performed in China, two in Egypt, and one in India. The results showed significant differences between the two operative approaches in terms of correction of kyphotic angle and intraoperative blood loss, but not in terms of operation time, hospital stay, fusion time, and loss of correction at the final follow-up.

CONCLUSION

The anterior and posterior approaches are equally good methods for treatment of thoracolumbar tuberculosis. The anterior approach results in less blood loss, whereas posterior instrumentation is better suited for correction of kyphotic angle.

[Optimizing the laparoscopic steps in right colectomy with complete mesocolic excision to reduce the intraoperative vascular injuries]

Laparoscopic right colectomy by the rule of complete mesocolic excision is becoming a standard operation for right colon cancer. Intraoperative iatrogenic vascular injuries are rare but disastrous complications. In addition to the dissection along the embryonic plane, reducing iatrogenic bleeding is of crucial importance to safeguard the surgical procedure. Keeping the operative field clear by gentle suction to have a good exposure is essential to identify the origin of bleeding, and then to make decision how to control the bleeding by bipolar coagulation, clipping and transection, suturing or conversion to open surgery. For small bleeding, the grasping forceps with bipolar coagulation or clipping would usually be effective. When there is laceration locating on the stem of superior mesenteric vein or Henle trunk, suturing with 4-0 or 5-0 prolene monofilament is suggested. Self-saphenous graft or bridge is advised for stem stricture after suturing. The ileocolic vessels are most anatomically constant, but with a different relationship between the artery and the vein. The tributaries to form the Henle trunk vary quite often, and they usually have close relation to the middle colic vein. Right colic artery rarely arises from the superior mesenteric artery, and the right colic vein seldom drains into the superior mesenteric vein. Anatomical variations are commonly observed in the pancreaticoduodenal area, where bleeding happens frequently. Selecting an optimal laparoscopic approach and dissecting order, awareness of vascular variation, and understanding the anatomical configuration of superior mesenteric vessels and their tributaries are important to minimize the intraoperative iatrogenic injuries during the meticulous dissections.

[Strategies for the prevention and control of bleeding due to vascular injury in thoracoscopic lung surgery]

The technique of thoracoscopic lung surgery has gradually matured. Nowadays, thoracoscope is recommended as the most preferred approach for surgical treatment of early stage non-small cell lung cancer in different guidelines. However, there are still some cases of accidential major bleeding due to vascular injury during thoracoscopic lung surgery. The wall of the hilum vessels is relatively thin. These vessels often involve a great portion of the cardiac output blood flow. Once the injury happened, the emergent condition may be life-threatening due to massive blood loss. Therefore, this became an important factor which hindered the development of thoracoscopic lung surgery. In this review, details of the vascular injury in thoracoscopic lung surgery were summarized, including the incidence of vascular injury, commonly injured sites and reasons of the injuries. Among all the cases of thoracoscopic major pulmonary resection, 2.9% to 9.2% may suffer from vascular injury during the operation. The most commonly injuried sites are pulmonary artery and the branches, and this is also the most critical situation during thoracoscopic lung surgery. Hilum adhesion is the most important risk factor for vascular injury. On the one hand, the suction-compressing angiorrhaphy technique was developed for bleeding control and angioplasty. On the other hand, the strategies like pre-control of the pulmonary, cut the bronchus in advance, and fire the bronchus and pulmonary artery together may decrease the incidence of vascular injury in patients with risk factors.

[Analysis on the occult blood loss after unicompartment knee arthroplasty]

OBJECTIVE

To calculate the volume of occult blood loss after unicompartment knee arthroplasty(UKA), and analyze its influential factors by comparing with total knee arthroplasty.

METHODS

A retrospective study of 130 cases from July 2012 to July 2015 were enrolled, of which and 65 cases were UKA, and 65 cases were TKA. In UKA group there were 27 males and 38 females, and the mean age was (62.3±4.3) years old (ranged, 50 to 82 years old). There were 14 cases older than 70 years old, while 51 cases among 50 to 70 years old. The mean Body mass index (BMI) was (23.9±2.6) kg/m²(ranged, 18.3 to 30.1 kg/m²). In TKA group there were 23 males and 42 females, and the mean age was (67.4±4.9) years old (ranged, 57 to 81 years old). There were 34 cases older than 70 years old, while 31 cases among 50 to 70 years old. The mean BMI was (25.6±2.3) kg/m²(ranged, 20.6 to 33.1 kg/m²). Hidden blood loss was calculated according to Gross equation, and the differences between the two groups including different ages and genders were observed subsequently. The differences of red blood cell change between two groups were observed dynamically postoperatively.

RESULTS

Postoperative hidden blood loss was (375.25±168.09) ml, HSS score was 87.11±5.39 in UKA group. Hidden blood loss was (898.81±221.47) ml, HSS score was 82.23±3.08 in TKA group. The differences between the two groups were significant. There were no significant differences in ages and genders. There were no significant relationship between hidden blood loss and HSS score or BMI, while the differences of red blood cell change were significant on the second day, the 4th day and the 5th day. There was no allogenic blood transfusion in UKA group, while 3 patients with transfusion in TKA group.

CONCLUSIONS

Hidden blood loss is part of total blood loss after UKA, and the volume in UKA is less than that in TKA. It could be compensated by the body and rarely affect the knee function. The hidden blood is not a risk factor of transfusion.

Anterior Versus Conventional Approach for Resection of Large Right Lobe Hepatocellular Carcinoma

PURPOSE

In this study, we aim to report the efficacy of using the anterior approach (AA) versus the conventional approach (CA), in surgical resection for large hepatocellular carcinoma (HCC) (≥7 cm) of the right hepatic lobe in terms of surgical and long-term outcomes.

MATERIALS AND METHODS

Between 2000 and 2006, 138 consecutive patients who underwent hepatic resection with curative intent for large right lobe HCC ≥7 cm were identified from a retrospective database. The 40 patients who had AA were compared with the remaining 98 patients who had CA. Clinicopathological features and surgical results were analyzed and prognostic factors were evaluated by multivariate analysis.

RESULTS

There was no significant difference between the two groups as regards clinical, laboratory, and pathological parameters. The operative results had shown a comparable proportion of patients who experienced massive operative blood loss and postoperative complications in the two groups. The AA group had a lower recurrence rate (P = 0·015), better disease-free survival (DFS) (P = 0·001), and overall survival than the CA group. Our study identified that AA is a prognostic factor of both overall survival and disease-free survival for large HCC ≥7 cm.

CONCLUSION

The AA is a safe and effective technique for right hepatic resection for large HCC and achieves more advantageous long survival outcome over the CA.

[Effects of tranexamic acid combined with temporary drain clamping on postoperative blood loss in total knee arthroplasty]

OBJECTIVE

To evaluate the efficacy and safety of one dose tranexamic acid combined with temporary drain lamping in primary unilateral total knee arthroplasty.

METHODS

Total 160 patients undergoing unilateral primary total knee arthroplasty between January 2012 and December 2013 were randomly divided into four groups(40 cases in each group):group A (the drain was clamped for 2 hours after the operation and the patients received 20 ml physiological saline), group B(the drain was clamped for 2 hours after the operation and the patients received 10 ml tranexamic acid and 10 ml physiological saline), group C (the drain was clamped for 4 hours after the operation and the patients received 20 ml physiological saline) and group D(the drain was clamped for 4 hours after the operation and the patients received 10 ml tranexamic acid and 10 ml physiological saline). The postoperative hemoglobin level, maximum hemoglobin loss, wound drainage, blood loss, the volume of blood transfusion, the number of patients inquiring blood transfusion, venous thrombo embolism rate, and ecchymosis rate were recorded and compared among the four groups.

RESULTS

There was no incision infection, severe hypoxia, and symptomatic pulmonary embolism in these groups. There were significant differences in hemoglobin content one day after operation in each group(F=12.26, P=0.000), in the hemoglobin content 7 days after operation in each group(F=20.74, P=0.000), in postoperative drainage in each group(F=38.71, P=0.000);in the amount of invisible red blood cell loss in each group(F=83.41, P=0.000), and in total red blood cell loss in each group(F=102.68, P=0.000). Color Doppler ultrasound examination found that the total incidence of VTE was 3%(5/160) and there were no significant differences in each group(P=0.892). There were no significant differences in postoperative subcutaneous ecchymosis area>1% incidence(P=0.143).

CONCLUSIONS

Topical tranexami acid treatment combined with temporary clamping of drain for 4 hours could reduce postoperative blood loss, blood transfusion, and ecchymosis rate without increasing the risk of thromboembolic event after total knee arthroplasty.

Blood Type O is not associated with increased blood loss in extensive spine surgery

STUDY OBJECTIVE

To investigate whether Type O blood group status is associated with increased intraoperative blood loss and requirement of blood transfusion in extensive spine surgery.

DESIGN

Retrospective comparative study.

SETTING

University-affiliated, non-profit teaching hospital.

MEASUREMENTS

Data from 1,050 ASA physical status 1, 2, 3, 4, and 5 patients who underwent spine surgeries involving 4 or more vertebral levels were analyzed. Patients with Type O blood were matched to similar patients with other blood types using propensity scores, which were estimated via demographic and morphometric data, medical history variables, and extent of surgery. Intraoperative estimated blood loss (EBL) was compared among matched patients using a linear regression model; intraoperative transfusion requirement in volume of red blood cells, fresh frozen plasma, platelet, cryoprecipitate, cell salvaged blood, volume of intraoperative infusion of hetastarch, 5% albumin, crystalloids, and hospital length of hospital (LOS) were compared using Wilcoxon rank-sum tests.

MAIN RESULTS

Intraoperative EBL and requirement of blood product transfusion were similar in patients with Type O blood group and those with other blood groups.

CONCLUSION

There was no association between Type O blood and increased intraoperative blood loss or blood transfusion requirement during extensive spine surgery, with similar hospital LOS in Type O and non-O patients.