Risk factors of bleeding during rectal cancer surgery in obese patients in Japan

BACKGROUND

According to several clinical trials for patients with rectal cancer, laparoscopic surgery significantly reduces intraoperative complications and bleeding compared with laparotomy and demonstrated comparable long-term results. However, obesity is considered one of the risk factors for increased surgical difficulty, including complication rate, prolonged operation time, and bleeding.

METHODS

Patients with clinical pathological stage II/III rectal cancer and a body mass index of ≥25 kg/m2 who underwent laparotomy or laparoscopic surgery between January 2009 and December 2013 at 51 institutions participating in the Japan Society of Laparoscopic Colorectal Surgery were included. These patients were divided into major bleeding (>500 mL) group and minor bleeding (≤500 mL) group. The risk factors of major bleeding were evaluated by univariate and multivariate analyses.

RESULTS

This study included 517 patients, of which 74 (19.9%) experienced major bleeding. Patient characteristics did not significantly differ between the two groups. The major bleeding group had a longer operative time (p < 0.001) and a larger tumor size than the minor bleeding group (p = 0.011). In the univariate analysis, age >65 years, laparotomy, operative time >300 min, and multivisceral resection were significantly associated with intraoperative massive bleeding. In the multivariate analysis, age >65 years (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.13-4.82), laparotomy (OR, 20.82; 95% CI, 11.56-39.75), operative time >300 min (OR, 5.39; 95% CI, 1.67-132), and multivisceral resection (OR, 10.72; 95% CI, 2.47-64.0) showed to be risk factors for massive bleeding.

CONCLUSION

Age >65 years, laparotomy, operative time >300 min, and multivisceral resection were risk factors for massive bleeding during rectal cancer surgery in patients with obesity.

Retrospective comparative clinical study on clinical effect of suture micromarsupialization on ranula

OBJECTIVES

This study aimed to evaluate the clinical effect of suture micromarsupialisation on ranula.  Methods: This is a retrospective comparative clinical study, the clinical data of 106 patients with simple ranula admitted to the Oral and Maxillofacial Surgery Department of Beijing Zhongguancun Hospital between August 2022 and May 2023 were collected. The patients were divided into the research group (55 patients), who underwent suture micromarsupialisation, and control group (51 patients), who underwent ranula resections. The therapeutic methods were compared regarding cure rate, surgical duration, intraoperative blood loss, 24-h postoperative pain score, intraoperative and postoperative complications, and recurrence rate.  Results: The difference in the total effective rate between the two groups was not statistically significant (98.18% vs. 96.08%, χ2 = 2.116, p = 0.347). Intraoperative blood loss (4.35 ± 1.19 vs. 26.33 ± 3.19), surgery duration (6.33 ± 1.43 vs. 26.33 ± 3.19) and the postoperative visual analogue scale score (0.32 ± 0.03 vs. 3.81 ± 0.15) in the research group were lower than in the control group (p < 0.05). The incidence rate of complications in the research group was lower than in the control group (7.27% vs. 25.49%, χ2 = 6.522, p = 0.011). The difference in the postoperative recurrence rate between the two groups was not statistically significant (3.63% vs. 9.80%, χ2 = 1.632, p = 0.201).  Conclusions: Suture micromarsupialisation is a conservative therapeutic method for intraoral ranula. The cure rate of suture micromarsupialisation is similar to that of traditional surgery. It is recommended to use this technique as a first-line conservative therapeutic method for intraoral ranula, as it has the advantages of minimal invasion, simple operation, no pain, no need for haemostasis and no complications.

The clinical effectiveness and safety of Zone III REBOA for resection of sacropelvic tumors in patients older than 70 years

BACKGROUND

REBOA is a method used to manage bleeding during surgery involving sacropelvic tumors. Nevertheless, studies on the use of REBOA among elderly people are lacking. The aim of this research was to investigate the efficacy and safety of Zone III REBOA in patients aged more than 70 years.

METHODS

A comparative study was conducted using case-control methods. A group of patients, referred to as Group A, who were younger than 70 years was identified and paired with a comparable group of patients, known as Group B, who were older than 70 years. Continuous monitoring of physiological parameters was conducted, and blood samples were collected at consistent intervals.

RESULTS

Totally, 188 participants were enrolled and received REBOA. Among the 188 patients, seventeen were aged more than 70 years. By implementing REBOA, the average amount of blood loss was only 1427 ml. Experiments were also conducted to compare Group A and Group B. No notable differences were observed in terms of demographic variables, systolic blood pressure (SBP), arterial pH, lactate levels, blood creatinine levels, potassium levels, or calcium levels at baseline. Additionally, after the deflation of the REBOA, laboratory test results, which included arterial pH, lactate, potassium concentration, calcium concentration, and blood creatinine concentration, were not significantly different (P > 0.05).

CONCLUSION

This study indicated that in selected patients aged more than 70 years can achieve satisfactory hemodynamic and metabolic stability with Zone III REBOA.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Advantages of robot-assisted resection of large mediastinal tumors: a single-center preliminary study

Current study aims to assess the safety and efficacy of robot-assisted thoracoscopic surgery (RATS) for sizable mediastinal masses with a minimum diameter ≥6 cm, compared with video-assisted thoracoscopic surgery (VATS) and open surgery. This study enrolled 130 patients with mediastinal tumors with no less than 6 cm diameter in Zhongnan Hospital, Wuhan University, including 33 patients who underwent RATS, 52 patients who underwent VATS and 45 patients who underwent open surgery. After classifying based on mass size and whether it has invaded or not, we compared their clinical characteristics and perioperative outcomes. There was no significant difference in age, gender, mass size, myasthenia gravis, mass location, pathological types (p > 0.05) in three groups. Patients undergoing open surgery typically presenting at a more advanced stage (p < 0.05). No obvious difference was discovered in the average postoperative length of stay, operation duration, chest tube duration and average postoperative day 1 drainage output between RATS group and VATS group (p > 0.05), while intraoperative blood loss in RATS group was significantly lower than VATS group (p = 0.046). Moreover, the postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss in RATS group were significantly lower than open surgery group (p < 0.001). RATS is a secure and efficient approach for removing large mediastinal masses at early postoperative period. In comparison with VATS, RATS is associated with lower intraoperative blood loss. Compared with open surgery, RATS is also associated with shorter postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss.

Tampa Difficulty Score: a novel scoring system for difficulty of robotic hepatectomy

BACKGROUND

Difficulty scoring system (DSS) has been established for laparoscopic hepatectomy and serves as useful tools to predict difficulty and guide preoperative planning. Despite increased adoption of robotics and its unique technical characteristics compared with laparoscopy, no DSS currently exists for robotic hepatectomy. We aimed to introduce a new DSS for robotic hepatectomy.

METHODS

A total of 328 patients undergoing a robotic hepatectomy were identified. After removing the first 24 major and 30 minor hepatectomies using cumulative-sum analysis, 274 patients were included in this study. Relevant clinical variables underwent linear regression using operative time and/or estimated blood loss (EBL) as markers for operative difficulty. Score distribution was analyzed to develop a difficulty-level grouping system.

RESULTS

Of the 274 patients, neoadjuvant chemotherapy; tumor location, size, and type; the extent of parenchymal resection; the need for portal lymphadenectomy; and the need for biliary resection with hepaticojejunostomy were significantly associated with operative time and/or EBL. They were used to develop the difficulty scores from 1 to 49. Grouping system results were group 1 (less demanding/beginner), 1 to 8 (n = 39); group 2 (intermediate), 9 to 24 (n = 208); group 3 (more demanding/advanced), 25 to 32 (n = 17); and group 4 (most demanding/expert), 33 to 49 (n = 10). When stratified by group, age, previous abdominal operation, Child-Pugh score, operative duration, EBL, major resection, 30-day mortality, 90-day mortality, and length of stay were significantly different among the groups.

CONCLUSION

In addition to established variables in laparoscopic systems, new factors such as the need for portal lymphadenectomy and biliary resection specific to the robotic approach have been identified in this new robotic DSS. Internal and external validations are the next steps in maturing this robotic DSS.

Use of Tranexamic Acid in Gender-Affirming Mastectomy Reduces Rates of Postoperative Hematoma and Seroma

BACKGROUND

The established safety and efficacy of tranexamic acid (TXA) in minimizing perioperative blood loss has led to increased interest within plastic surgery. Prior studies have demonstrated decreased edema and ecchymosis and reduced rates of postoperative collection with administration of TXA; however, its use has not been reported in gender-affirming mastectomy. This represents the first study to evaluate the effects of TXA on postoperative outcomes in patients undergoing gender-affirming mastectomy.

METHODS

A single-center cohort study was performed analyzing all consecutive patients undergoing gender-affirming mastectomy with the senior author (R.B.-L.) between February of 2017 and October of 2022. Beginning in June of 2021, all patients received 1000 mg of TXA intravenously before incision and 1000 mg at the conclusion of the procedure. Patients were stratified according to intraoperative administration of TXA, with demographic characteristics, surgical characteristics, and postoperative outcomes compared between groups.

RESULTS

A total of 851 patients underwent gender-affirming mastectomy. Of these, 646 cases were performed without TXA, and 205 patients received intravenous TXA intraoperatively, as described previously. Patients who received TXA had significantly lower rates of seroma (20.5% versus 33.0%; P < 0.001) and hematoma (0.5% versus 5.7%; P = 0.002). There was no difference in rates of surgical-site infection ( P = 0.74). TXA use was not associated with increased rates of venous thromboembolism ( P = 0.42).

CONCLUSIONS

Intraoperative administration of TXA in patients undergoing gender-affirming mastectomy may safely reduce the risk of postoperative seroma and hematoma without increased risk of thromboembolic events. Additional data collection and prospective studies are warranted to corroborate these findings.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Predictors of Blood Transfusion in Patients Undergoing Cytoreductive Surgeries for Ovarian Malignancy

OBJECTIVES

The aims of this study were to describe the baseline estimated blood loss (EBL) in surgery and transfusion rate in patients undergoing cytoreductive surgeries for ovarian malignancy, and identify perioperative variables associated with blood loss and transfusion.

METHODS

A retrospective cohort study at a single institution was performed that included patients with known or suspected ovarian malignancy undergoing cytoreductive surgery between 2016 and 2021. t tests, χ2 tests, and multiple logistic regression analyses were used.

RESULTS

Among 44 patients meeting inclusion criteria, 61% received perioperative blood transfusion. There were significant differences in EBL and preoperative hemoglobin levels between patients who did and did not receive transfusion (EBL 442.6 vs 236.8 mL, P = 0.0008; preoperative hemoglobin 10.2 vs 11.2 g/dL, P = 0.049). After adjusting for preoperative hemoglobin, the risk of transfusion increased for each additional 200 mL of EBL (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.5-9.5). Stratified by race, the association between EBL and transfusion risk remained statistically significant only for non-Latinx White patients (OR 6.1, 95% CI 1.7-21.9), who made up 77% of the study population, but not for patients of other races and ethnicities (OR 1.0, 95% CI 0.16-6.42).

CONCLUSIONS

Perioperative blood transfusion is common in patients undergoing cytoreductive surgery. In this study, EBL and preoperative hemoglobin levels were significantly associated with transfusion receipt. Clinicians should optimize hemoglobin levels and intraoperative blood conservation strategies to reduce the need for transfusion. The results also highlight the importance of considering racial and ethnic differences when developing strategies to reduce transfusion risk.

The application of a single-hand-operated hepatic pedicle clamping clamp in laparoscopic hepatectomy

OBJECTIVE

In this paper, a single-hand-operated hepatic pedicle clamp was introduced, and its application value in laparoscopic liver tumor resection was preliminarily discussed.

METHODS

The clinical data of 67 patients who underwent laparoscopic liver tumor resection at the First Affiliated Hospital of Wannan Medical College from March 2019 to October 2023 were retrospectively analyzed. The Pringle maneuver was performed with a hepatic pedicle clamp during the operation. The preoperative, intraoperative and postoperative clinical data were observed and recorded.

RESULTS

Sixty-seven patients had a median block number, block time, intraoperative blood loss, and postoperative length of hospital stay of 4, 55 min, 400 ml, and 7 days, respectively. The average operation time was 304.9±118.4 min, the time required for each block was 3.2±2.4 s, and the time required for each removed block was 2.6±0.7 s. None of the patients developed portal vein thrombosis or hepatic artery aneurysm formation.

CONCLUSION

The hepatic pedicle clamping clamp is simple to use in laparoscopic hepatectomy, optimizes the operation process, and has a reliable blocking effect. It is recommended for clinical application.

Comparison of the perioperative outcomes of robot-assisted laparoscopic transperitoneal versus retraperitoneal partial nephrectomy for posterior-lateral renal tumors: a systematic review and meta-analysis

The study aims to assess the available literature and compare the perioperative outcomes of robotic-assisted partial nephrectomy (RAPN) for posterior-lateral renal tumors using transperitoneal (TP) and retroperitoneal (RP) approaches. Systematically searched the Embase, PubMed, and Cochrane Library databases for literature. Eligible studies were those that compared TP-RAPN and RP-RAPN for posterior-lateral renal tumors. The data from the included studies were analyzed and summarized using Review Manager 5.3, which involved comparing baseline patient and tumor characteristics, intraoperative and postoperative outcomes, and oncological outcomes. The analysis included five studies meeting the inclusion criteria, with a total of 1440 patients (814 undergoing RP-RAPN and 626 undergoing TP-RAPN). Both groups showed no significant differences in age, gender, BMI, R.E.N.A.L. score, and tumor size. Notably, compared to TP-RAPN, the RP-RAPN group demonstrated shorter operative time (OT) (MD: 17.25, P = 0.01), length of hospital stay (LOS) (MD: 0.37, P < 0.01), and lower estimated blood loss (EBL) (MD: 15.29, P < 0.01). However, no significant differences were found between the two groups in terms of warm ischemia time (WIT) (MD: -0.34, P = 0.69), overall complications (RR: 1.25, P = 0.09), major complications (the Clavien-Dindo classification ≥ 3) (RR: 0.97, P = 0.93), and positive surgical margin (PSM) (RR: 1.06, P = 0.87). The systematic review and meta-analysis suggests RP-RAPN may be more advantageous for posterior-lateral renal tumors in terms of OT, EBL, and LOS, but no significant differences were found in WIT, overall complications, major complications, and PSM. Both surgical approaches are safe, but a definitive advantage remains uncertain.

Enhancing surgical performance: the role of robotic surgery in myomectomies, a systematic review and metanalysis

Examine the role, benefits, and limitations of robotic surgery in myomectomies compared to laparoscopic and open surgical approaches. This review sourced data from CENTRAL, Pubmed, Medline, and Embase up until May 1, 2023. Full articles comparing clinical outcomes of robotic myomectomy with open or laparoscopic procedures were included without language restriction. Initially, 2150 records were found. 24 studies were finally included for both qualitative and quantitative analyses. Two investigators independently assessed all reports following PRISMA guidelines. Meta-analysis was conducted using the software "Review Manager Version 5.4". Risk-of-bias was assessed using the Newcastle-Ottawa scale. Sensitivity analysis was conducted, when feasible. In a comparison between robotic and laparoscopic myomectomies, no significant difference was observed in fibroid weights and the size of the largest fibroid. Robotic myomectomy resulted in less blood loss, but transfusion rates were comparable. Both methods had similar complication rates and operative times, although some robotic studies showed longer durations. Conversion rates favored robotics. Hospital stays varied widely, with no overall significant difference, and pregnancy rates were similar between the two methods. When comparing robotic to open myomectomies, open procedures treated heavier and larger fibroids. They also had greater blood loss, but the robotic approach required fewer transfusions. The complication rate was slightly higher in open procedures. Open surgeries were generally faster, postoperative pain scores were similar, but hospital stays were longer for open procedures. Pregnancy rates were comparable for both robotic and open methods. Robotic surgery offers advancement in myomectomy procedures by offering enhanced exposure and dexterity, leading to reduced blood loss and improved patient outcomes. PROSPERO registration: CRD42023462348.

Analysis of factors affecting intraoperative hemorrhage during percutaneous nephrolithotomy and establishment of nomogram model

Intraoperative hemorrhage is an important factor affecting intraoperative safety and postoperative patient recovery in percutaneous nephrolithotomy (PCNL). This study aimed to identify the factors that influence intraoperative hemorrhage during PCNL and develop a predictive nomogram model based on these factors.A total of 118 patients who underwent PCNL at the Department of Urology, The Affiliated Huai'an No.1 People's Hospital of Nanjing Medical University from January 2021 to September 2023 was included in this study. The patients were divided into a hemorrhage group (58 cases) and a control group (60 cases) based on the decrease in hemoglobin levels after surgery. The clinical data of all patients were collected, and both univariate analysis and multivariate logistic regression analysis were conducted to identify the independent risk factors for intraoperative hemorrhage during PCNL. The independent risk factors were used to construct a nomogram model using R software. Additionally, receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA) were utilized to evaluate the model.Multivariate logistic regression analysis revealed that diabetes, long operation time and low psoas muscle mass index (PMI) were independent risk factors for intraoperative hemorrhage during PCNL (P < 0.05). A nomogram model was developed incorporating these factors, and the areas under the ROC curve (AUCs) in the training set and validation set were 0.740 (95% CI: 0.637-0.843) and 0.742 (95% CI: 0.554-0.931), respectively. The calibration curve and Hosmer-Lemeshow test (P = 0.719) of the model proved that the model was well fitted and calibrated. The results of the DCA showed that the model had high value for clinical application.Diabetes, long operation time and low PMI were found to be independent risk factors for intraoperative hemorrhage during PCNL. The nomogram model based on these factors can be used to predict the risk of intraoperative hemorrhage, which is beneficial for perioperative intervention in high-risk groups to improve the safety of surgery and reduce the incidence of postoperative complications.

Safety and complications of continuation of aspirin therapy in patients undergoing robot-assisted laparoscopic simple prostatectomy

To evaluate the safety and feasibility of continued perioperative aspirin at the time of robotic assisted simple prostatectomy (RASP). We performed a retrospective review of our IRB approved institutional database of patients who underwent RASP between 2013 and 2022. Comparative groups included patients taking aspirin in the perioperative period and those not taking aspirin pre-operatively. The primary outcome was any post-operative bleeding related complication using the modified Clavien-Dindo classification. Secondary outcomes included the identification of risk factors for increased blood loss in the entire study population, operative time, and blood transfusion requirement. 143 patients underwent RASP of which 55 (38.5%) patients continued perioperative aspirin therapy and 88 (61.5%) patients did not. Baseline demographics were similar between groups. Patients taking perioperative aspirin had a higher rate of hypertension (74.5% vs 58.0%, p = 0.04) and other cardiovascular disease (30.9% vs 11.4%, p = 0.007). Postoperative complications were similar between the groups (Clavien-Dindo ≥ 3; p = 0.43). Median blood loss (150 cc vs 150 cc, p = 0.38), percentage drop in hemoglobin (13.4 vs 13.2, p = 0.94) and blood transfusion rate (3.6 vs 1.1, p = 0.56) were also similar between groups. The median blood loss was 150 ml for the whole study population. On regression analysis, neither aspirin nor any other variable was associated with increased blood loss (> 150 ml). Aspirin can be safely continued perioperatively in patients undergoing RASP without any risk of bleeding related complications, blood loss, or increased transfusion rate.

Robotic resection of presacral tumors

BACKGROUND

Presacral tumors are a rare entity typically treated with an open surgical approach. A limited number of minimally invasive resections have been described. The aim of the study is to evaluate the safety and efficacy of roboticresection of presacral tumors.

METHODS

This is a retrospective single system analysis, conducted at a quaternary referral academic healthcare system, and included all patients who underwent a robotic excision of a presacral tumor between 2015 and 2023. Outcomes of interest were operative time, estimated blood loss, complications, length of stay, margin status, and recurrence rates.

RESULTS

Sixteen patients (11 females and 5 males) were included. The median age of the cohort was 51 years (range 25-69 years). The median operative time was 197 min (range 98-802 min). The median estimated blood loss was 40 ml, ranging from 0 to 1800 ml, with one patient experiencing conversion to open surgery after uncontrolled hemorrhage. Urinary retention was the only postoperative complication that occurred in three patients (19%) and was solved within 30 days in all cases. The median length of stay was one day (range 1-6 days). The median follow-up was 6.7 months (range 1-110 months). All tumors were excised with appropriate margins, but one benign and one malignant tumor recurred (12.5%). Ten tumors were classified as congenital (one was malignant), two were mesenchymal (both malignant), and five were miscellaneous (one malignant).

CONCLUSIONS

Robotic resection of select presacral pathology is feasible and safe. Further studies must be conducted to determine complication rates, outcomes, and long-term safety profiles.

A Retrospective Study in 12-Year cohort of 216 Parturients with Invasive Placentation in a Tertiary Care Centre in Oman: Clinical Outcomes Indicate Severe Maternal Morbidity

Placenta accreta spectrum (PAS) comprising placenta accreta, increta, and percreta, is 1 of the leading causes of peripartum hemorrhage and accounts for up to 50% of all cesarean hysterectomies (CH). We analyzed the data of 216 parturients with PAS who underwent cesarean delivery (CD) and/or CH. Intraoperative surgical complications were noted in 215 (99.5%). The mean estimated blood loss was 2743 (1790) mL, and 105 parturients (48.6%) lost ≥2500 mL. The patients experienced high rates of severe acute maternal morbidity [162 (75%)], hysterectomy [82 (38%)], large volume blood loss, blood transfusion, peripartum anemia, and prolonged hospital stay.

[Comparison of Clinical Effects of Cortical Bone Trajectory Screws and Traditional Pedicle Screws in Posterior Lumbar Fusion]

Objective

To compare the clinical effects of cortical bone trajectory screws and traditional pedicle screws in posterior lumbar fusion.

Methods

A retrospective study was conducted to analyze lumbar degeneration patients who underwent surgical treatment at our hospital between January 2016 and January 2019. A total of 123 patients who met the inclusion criteria were enrolled. The subjects were divided into two groups according to their surgical procedures and the members of the two groups were matched by age, sex, and the number of fusion segments. There were 63 patients in the traditional pedicle screws (PS) group and 60 in the cortical bone trajectory screws (CBTS) group. The outcomes of the two groups were compared. The primary outcome measures were perioperative conditions, including operation duration, estimated intraoperative blood loss (EBL), and length-of-stay (LOS), visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, and interbody fusion rate. The secondary outcome measures were the time to postoperative ambulation and the incidence of complications. VAS scores and ODI scores were assessed before operation, 1 week, 1 month, 3 months, and 12 months after operation, and at the final follow-up. The interbody fusion rate was assessed in 1 year and 2 years after the operation and at the final follow-up.

Results

The CBTS group showed a reduction in operation duration ([142.8±13.1] min vs. [174.7±15.4] min, P<0.001), LOS ([9.5±1.5] d vs. [12.0±2.0] d, P<0.001), and EBL ([194.2±38.3] mL vs. [377.5±33.1] mL, P<0.001) in comparison with the PS group. The VAS score for back pain in the CBTS group was lower than that in the PS group at 1 week and 1 month after operation and the ODI score in the CBTS group was lower than that in the PS group at 1 month after operation, with the differences being statistically significant (P<0.05). At each postoperative time point, the VAS score for leg pain and the interbody fusion rate did not show significant difference between the two groups. The VAS score for back and leg pain and the ODI score at each time point after operation in both the CBTS group and the PS group were significantly lower than those before operation (P<0.05). No significant difference was found in the time to postoperative ambulation or the overall complication incidence between the two groups.

Conclusion

The CBTS technique could significantly shorten the operation duration and LOS, reduce EBL, and achieve the same effect as the PS technique does in terms of intervertebral fusion rate, pain relief, functional improvement, and complication incidence in patients undergoing posterior lumbar fusion.

Efficacy of Flexible Ureteroscopy Lithotripsy and Percutaneous Nephrolithotomy in the Treatment of Patients with Kidney Stones and Their Impact on Inflammatory Response and Renal Function

BACKGROUND

Kidney stones are one of the most common benign diseases in urology. As technology updates and iterates, more minimally invasive and laparoscopic surgeries with higher safety performance appear. This paper explores the effectiveness of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) in treating kidney stones, focusing on their effects on inflammatory responses and renal function.

METHODS

We conducted a retrospective analysis of 200 patients with kidney stones treated in our hospital between June 2019 and June 2023. 100 patients who underwent RIRS were included in the RIRS group. Another 100 patients who underwent PCNL treatment were included in the PCNL group. The intraoperative blood loss, operation duration, and hospitalization time of the two groups of patients were recorded and compared. The enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of inflammatory factors in the serum of the two groups of patients: [serum amyloid A (SAA), interleukin-6 (IL-6) and high-sensitivity C-reactive protein (CRP)] and renal function index [blood urea nitrogen (BUN), creatinine (Scr) and serum cystatin (Cys-c)]. The two groups of patients were recorded separately: Postoperative complications and stone-free rate.

RESULTS

Operation duration was longer for the RIRS group than the PCNL group, which exhibited significantly less intraoperative blood loss and shorter hospital stays (p < 0.05). Before surgery, there was no statistically significant difference in the serum levels of SAA, IL-6, and CRP between the two groups of patients (p > 0.05). On the first day after surgery, the serum SAA levels in both groups were lower than before surgery, IL-6 and CRP levels were higher than before surgery, and the serum levels of SAA, IL-6, and CRP in the RIRS group were significantly lower than those in the PCNL group. The difference was statistically significant (p < 0.05). Before surgery, there was no statistically significant difference in the serum BUN, Scr, and Cys-c levels between the two groups of patients (p > 0.05). On the first day after surgery, the serum BUN, Scr, and Cys-c levels of the two groups of patients were significantly higher than those before surgery. The serum BUN, Scr, and Cys-c levels of the RIRS group were significantly lower than those of the PCNL group, and the difference was statistically significant (p < 0.05). Both surgical methods have sound stone-clearing effects regarding long-term stone clearance rates 1 month and 3 months after surgery (p > 0.05). PCNL had a better stone clearance rate on the 2nd postoperative day (p < 0.05). The incidence of postoperative complications in the RIRS group was significantly lower than that in the PCNL group, and the difference was statistically significant (p < 0.05).

CONCLUSION

For kidney stones ≤2 cm, PCNL showed higher stone clearance rates on the second postoperative day. However, RIRS and PCNL demonstrated adequate long-term stone clearance at 1 and 3 months post-surgery. Both surgical methods are safe and effective, and RIRS is safer than PCNL. Compared with PCNL, RIRS is a new method of kidney stone operation, which has less trauma to the patient's body and fewer complications after the operation, speeding up the recovery process of the patient.

The impact of venous resection in pancreatoduodectomy: A systematic review and meta-analysis

BACKGROUND

Vein resection pancreatoduodenectomy (VRPD) may be performed in selected pancreatic cancer patients. However, the main risks and benefits related to VRPD remain controversial.

OBJECTIVE

This review aimed to evaluate the risks and survival benefits that the VRPD may add when compared with standard pancreatoduodenectomy (PD).

METHODS

A systematic review and meta-analysis of studies comparing VRPD and PD were performed.

RESULTS

VRPD was associated with a higher risk for postoperative mortality (risk difference: -0.01; 95% confidence interval [CI] -0.02 to -0.00) and complications (risk difference: -0.05; 95% CI -0.09 to -0.01) than PD. The length of hospital stay was not different between the groups (mean difference [MD]: -0.65; 95% CI -2.11 to 0.81). In the VRPD, the operating time was 69 minutes higher on average (MD: -69.09; 95% CI -88.4 to -49.78), with a higher blood loss rate (MD: -314.04; 95% CI -423.86 to -195.22). In the overall survival evaluation, the hazard ratio for mortality during follow-up on the group of VRPD was higher compared to the PD group (hazard ratio: 1.13; 95% CI 1.03-1.23).

CONCLUSION

VRPD is associated with a higher risk of short-term complications and mortality and a lower probability of survival than PD. Knowing the risks and potential benefits of surgery can help clinicians to properly manage pancreatic cancer patients with venous invasion. The decision for surgery with major venous resection should be shared with the patients after they are informed of the risks and prognosis.

Natural course of hemoglobin level after total knee arthroplasty and the benefit of tranexamic acid injection in the joint

We retrospectively investigated the natural course of hemoglobin (Hb) level after total knee arthroplasty (TKA) and identified the benefit of tranexamic acid injection at the operation field for unilateral TKA patients who have not received blood transfusions.There were 115 cases conducted by a surgeon who performed TKA without injecting tranexamic acid and 62 cases by another surgeon with injection. During 2-weeks of hospitalization, Hb level was checked on the day of surgery and 1, 2, 3, 5, 7, 11 days after surgery.Regardless of whether whom the operator was and tranexamic acid was injected or not, the same natural course of Hb level after TKA was observed. The lowest value of Hb was shown at postoperative day 3, after which it tended to recover. In repeated measures analysis of variance test, mean difference from preoperative Hb level showed a statistically significant difference between tranexamic acid injected and noninjected groups (P = .01). In post hoc test, the differences from preoperative Hb levels were significantly lower at all measurements in surgeon with injection of tranexamic acid.When deciding whether to transfuse after TKA, it should be noted that the patient tends to show the lowest Hb level on postoperative day 3. Also, the authors emphasize that tranexamic acid injection in the joint at the operation field is an effective method to reduce the loss of Hb after TKA.

Radical Cystectomy after Previous Radiation or Pelvic Surgery: Is It Associated with Increased Morbidity?

BACKGROUND

Radical cystectomy is a complicated surgery with significant risks. Complications of Clavien-Dindo grade 3-4 range from 25% to 40% while risk of mortality is 2%. Pelvic surgery or radiotherapy prior to radical cystectomy increases the challenges of this surgery.

OBJECTIVES

To assess whether radical cystectomy performed in patients with prior history of pelvic surgery or radiation was associated with increased frequency of Clavien-Dindo grade 3 or higher complications compared to patients without prior pelvic intervention.

METHODS

We retrospectively evaluated all patients who underwent radical cystectomy at our center over a 7-year period. All patients with pelvic radiation or surgery prior to radical cystectomy comprised group 1, while group 2 included the remaining patients.

RESULTS

In our study, 65 patients required radical cystectomy at our institution during the study period. Group 1 was comprised of 17 patients and group 2 included 48 patients. Four patients from group 2 received orthotopic neobladder, while an ileal conduit procedure was performed in the remaining patients. Estimated blood loss and the amount of blood transfusions given was the only variable found to be statistically different between the two groups. One patient from group 1 had four pelvic interventions prior to surgery, and her cystectomy was aborted.

CONCLUSIONS

Radical cystectomy may be safely performed in patients with a history of pelvic radiotherapy or surgery, with complication rates similar to those of non-irradiated or operated pelvises.

Meta-analysis of the efficacy of Da Vinci robotic or laparoscopic distal subtotal gastrectomy in patients with gastric cancer

BACKGROUND

Robotic-assisted gastrectomy has been used for treating gastric cancer since 2002. This meta-analysis was conducted to systematically evaluate the efficacy of Da Vinci robotic distal subtotal gastrectomy (RDG) or laparoscopic distal subtotal gastrectomy (LDG) in patients with gastric cancer.

METHODS

We conducted searches in domestic and foreign databases, and collected literature in Chinese and English on the efficacy of RDG and LDG for gastric cancer that have been published since the inception of the database. RevMan 5.4.1 was used for meta-analysis and drawing and Stata14.0 was used for publication bias analysis.

RESULTS

A total of 3293 patients in 15 studies were included, including 1193 patients in the RDG group and 2100 patients in the LDG groups respectively. The meta-analysis showed that intraoperative blood loss was significantly lower and the number of resected lymph nodes was higher in the RDG group compared to that in the LDG group. In addition, the times to first postoperative food intake and postoperative hospital stay were shortened, and there was a longer length of distal resection margin and prolonged duration of operation. No significant differences were found between the 2 groups with respect to the first postoperative anal exhaust time, length of proximal resection margin, total postoperative complication rate, postoperative anastomotic leakage rate, incidence of postoperative gastric emptying disorder, pancreatic fistula rate, recurrence rate, and mortality rate.

CONCLUSION

RDG is a safe and feasible treatment option for gastric cancer, and it is non-inferior or even superior to LDG with respect to therapeutic efficacy and radical treatment.

Risk Factors for Severe Bleeding Complications in Vitreoretinal Surgery and the Role of Antiplatelet or Anticoagulant Agents

PURPOSE

To evaluate the influences and risk factors for severe bleeding complications during vitreoretinal surgery and to investigate the role of antiplatelet and anticoagulant agents.

DESIGN

Prospective trial.

PARTICIPANTS

Patients undergoing vitreoretinal surgery.

METHODS

The procedures included were pars plana vitrectomy and scleral buckling. We developed a uniform classification to grade the bleeding severity. Bleeding was graded on an ordinal scale ranging from 0 to 5. Immediately after surgery and 1 day later, the incidence and the severity of bleeding events was documented on a standardized form. A grade of 3 or more was defined as severe bleeding. Furthermore, the influence of known systemic disorders before surgery, the type of anesthesia, type of surgical procedure, intraoperative blood pressure, and the use or change of antiplatelet or anticoagulant agents on intraoperative bleeding was analyzed.

MAIN OUTCOME MEASURES

Incidence and risk factors for severe intraoperative bleeding events.

RESULTS

Data from 374 eyes undergoing vitreoretinal procedures were included in our study (mean age, 67.6 ± 12.9 years). A severe intraoperative bleeding event was observed in 15 eyes (4%). We found that concomitant diseases such as diabetes mellitus and carotid artery stenosis, the presence of diabetic retinopathy, younger age, and scleral buckling combined with a transscleral puncture were associated significantly with severe bleeding events. By contrast, use of antiplatelet or anticoagulant agents, or both, had no significant influence on severe intraoperative bleeding events.

CONCLUSIONS

Although external manipulations during buckling surgery (e.g., drainage of subretinal fluid) and concomitant diseases such as diabetes mellitus and carotid artery stenosis influences the risk of severe intraoperative bleeding events, we did not detect an increased risk related to coexisting antiplatelet or anticoagulant medication use, or both.

Retroperitoneal versus transperitoneal approach for elective open abdominal aortic aneurysm repair

BACKGROUND

There has been extensive debate in the surgical literature regarding the optimum surgical access approach to the infrarenal abdominal aorta during an operation to repair an abdominal aortic aneurysm. The published trials comparing retroperitoneal (RP) and transperitoneal (TP) aortic surgery show conflicting results. This is an update of the review first published in 2016.

OBJECTIVES

To assess the effectiveness and safety of the retroperitoneal versus transperitoneal approach for elective open abdominal aortic aneurysm repair on mortality, complications, hospital stay and blood loss.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trials registers to 30 November 2020. The review authors searched the Chinese Biomedical Literature Database and handsearched reference lists of relevant articles to identify additional trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that assessed the RP approach versus the TP approach for elective open abdominal aortic aneurysm (AAA) repair. There were no restrictions on language or publication status.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included trials. We resolved any disagreements through discussion with a third review author. Two review authors independently assessed the risk of bias in included trials with the Cochrane risk of bias tool. For dichotomous outcomes, we calculated the odds ratio (OR) with the corresponding 95% confidence interval (CI). For continuous data, we calculated a pooled estimate of treatment effect by calculating the mean difference (MD) and standard deviation (SD) with corresponding 95% CIs. We pooled data using a fixed-effect model, unless we identified heterogeneity, in which case we used a random-effects model. We used GRADE to assess the overall certainty of the evidence. We evaluated the outcomes of mortality, complications, intensive care unit (ICU) stay, hospital stay, blood loss, aortic cross-clamp time and operating time.

MAIN RESULTS

We identified no new studies from the updated searches. After reassessment, we included one study which had previously been excluded. Five RCTs with a combined total of 152 participants are included. The overall certainty of the evidence ranged from low to very low because of the low methodological quality of the included trials (unclear random sequence generation method and allocation concealment, and no blinding of outcome assessors), small sample sizes, small number of events, high heterogeneity and inconsistency between the included trials, no power calculations and relatively short follow-up. There was no evidence of a difference between the RP approach and the TP approach regarding mortality (odds ratio (OR) 0.32, 95% CI 0.01 to 8.25; 3 studies, 110 participants; very low-certainty evidence). Similarly, there was no evidence of a difference in complications such as hematoma (OR 0.90, 95% CI 0.13 to 6.48; 2 studies, 75 participants; very low-certainty evidence), abdominal wall hernia (OR 10.76, 95% CI 0.55 to 211.78; 1 study, 48 participants; very low-certainty evidence), or chronic wound pain (OR 2.20, 95% CI 0.36 to 13.34; 1 study, 48 participants; very low-certainty evidence) between the RP and TP approaches in participants undergoing elective open AAA repair. The RP approach may reduce ICU stay (mean difference (MD) -19.02 hours, 95% CI -30.83 to -7.21; 3 studies, 106 participants; low-certainty evidence); hospital stay (MD -3.30 days, 95% CI -4.85 to-1.75; 5 studies, 152 participants; low-certainty evidence); and blood loss (MD -504.87 mL, 95% CI -779.19 to -230.56; 4 studies, 129 participants; very low-certainty evidence). There was no evidence of a difference between the RP approach and the TP approach regarding aortic cross-clamp time (MD 0.69 min, 95% CI -7.23 to 8.60; 4 studies, 129 participants; very low-certainty evidence) or operating time (MD -15.94 min, 95% CI -34.76 to 2.88; 4 studies, 129 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Very low-certainty evidence from five small RCTs showed no clear evidence of a difference between the RP approach and the TP approach for elective open AAA repair in terms of mortality, or for rates of complications including hematoma (very low-certainty evidence), abdominal wall hernia (very low-certainty evidence), or chronic wound pain (very low-certainty evidence). However, a shorter intensive care unit (ICU) stay and shorter hospital stay was probably indicated following the RP approach compared to the TP approach (both low-certainty evidence). A possible reduction in blood loss was also shown after the RP approach (very low-certainty evidence). There is no clear difference between the RP approach and TP approach in aortic cross-clamp time or operating time. Further well-designed, large-scale RCTs assessing the RP approach versus TP approach for elective open AAA repair are required.

Risk factors associated with postoperative respiratory failure in tuberculous empyema patients

Our objective was to identify independent risk factors for predicting which patients in the Chinese population would likely develop respiratory failure.A descriptive analysis was conducted of demographic and clinical data of patients with tuberculous empyema (TE) admitted to the Beijing Chest Hospital, Capital Medical University between January 2001 and January 2020. Risk factors associated with postsurgical respiratory failure in TE patients were identified based on results of analyses based on univariable and multivariable logistic regression models.A total of 139 TE patients who underwent surgical treatment in the Beijing Chest Hospital, Capital Medical University from January 2001 to January 2020 were enrolled in this study. Cases included 109 male and 30 female patients, with an overall mean age (range 17-73) of 39.3 years. Of 139 TE patients, 26 (18.7%) experienced respiratory failure after surgery. Among significant risk factors for postsurgical respiratory failure, intraoperative blood loss volume greater than 1000 mL had the highest odds ratio value of 6.452. In addition, a pathologic preoperative pulmonary function test result showing a high partial pressure of carbon dioxide level was an independent risk factor for respiratory failure. Moreover, the presence of tuberculosis lesions in the contralateral lung was another significant risk factor for respiratory failure, as determined using multivariate analysis.Respiratory failure is a predominant complication experienced by TE patients undergoing surgery. High intraoperative blood loss, high preoperative high partial pressure of carbon dioxide level, and tuberculosis lesion(s) in the contralateral lung of TE patients were associated with increased risk of postoperative respiratory failure.

Surgical management for lumbar brucella spondylitis: Posterior versus anterior approaches

There has been no ideal surgical approach for lumbar brucella spondylitis (LBS). This study aims to compare clinical efficacy and safety of posterior versus anterior approaches for the treatment of LBS.From April 2005 to January 2015, a total of 27 adult patients with lumbar brucella spondylitis were recruited in this study. The patients were divided into 2 groups according to surgical approaches. Thirteen cases in group A underwent 1-stage anterior debridement, fusion, and fixation, and 14 cases in group B underwent posterior debridement, bone graft, and fixation. The clinical and surgical outcomes were compared in terms of operative time, intraoperative blood loss, hospitalizations, bony fusion time, complications, visual analog scale score, recovery of neurological function, deformity correction.Lumbar brucella spondylitis was cured, and the grafted bones were fused within 11 months in all cases. It was obviously that the operative time and intraoperative blood loss of group A were more than those of group B (P = .045, P = .009, respectively). Kyphotic deformity was signifcantly corrected in both groups after surgery; however, the correction rate was higher in group B than in group A (P = .043). There were no significant differences between the two groups in hospitalizations, bony fusion time, and visual analog scale score in the last follow-up (P = .055, P = .364, P = .125, respectively).Our results suggested that both anterior and posterior approaches can effectively cure lumbar brucella spondylitis. Nevertheless, posterior approach gives better kyphotic deformity correction, less surgical invasiveness, and less complications.

Robot-assisted vs freehand cannulated screw placement in femoral neck fractures surgery: A systematic review and meta-analysis

BACKGROUND

Several studies have reported that medical robot-assisted method (RA) might be superior to conventional freehand method (FH) in orthopedic surgery. Yet the results are still controversial, especially in terms of femoral neck fractures surgery. Here, 2 methods were assessed based on current evidence.

METHODS

Electronic databases including Cochrane Library, PubMed, Web of Science. and EMBASE were selected to retrieved to identify eligible studies between freehand and RAs in femoral neck fractures, with 2 reviewers independently reviewing included studies as well as collecting data.

RESULTS

A total of 5 studies with 331 patients were included. Results indicated that 2 surgical methods were equivalent in terms of surgical duration, Harris score, fracture healing time, fracture healing proportion and complications, while RA showed clinical benefits in radiation exposure, intraoperative bleeding, total drilling times, and screw parallelism.

CONCLUSIONS

Current literature revealed significantly difference between 2 techniques and suggested that RA might be beneficial for patients than freehand method.

Liver retraction using n-butyl-2-cyanoacrylate glue during laparoscopic cholecystectomy

There might be a thick "protrusion" in the visceral surface of hepatic quadrate lobe during the laparoscopic cholecystectomy (LC), which affects the surgical fields and consequently triggers high risks of biliary tract injury. Although n-butyl-2-cyanoacrylate (NBCA) glue has been applied to laparoscopic upper abdominal surgery for liver retraction, there is still no consensus on its safety and feasibility in LC. In this study, we investigated the safety, feasibility, and effectiveness of liver retraction using NBCA glue for these patients which have the thick "protrusion" on the square leaf surface of the liver during LC.Fifty-seven patients presenting thick "protrusion" hepatic quadrate lobe were included in our retrospective study. We performed LC in the presence of NBCA glue (n = 30, NBCA group) and absence of NBCA glue (n = 27, non-NBCA group), respectively. NBCA was used to fix the thick "protrusion" of the liver leaves to the hepatic viscera surface, which contributed to the revelation of the gallbladder triangle. The operation time, blood loss, postoperative hospitalization, and liver function were compared between the 2 groups.Both the groups' patients accomplished the operation in the laparoscopy. There was no mortality and no additional incision during operation. No severe complications including bile duct injury were available after surgery and no postoperative NBCA-related complications occurred after 9- to 30 months' follow-up. The time of operation in NBCA group showed significant decrease compared with that of non-NBCA group (48.33 ± 16.15 vs 65.00 ± 22.15 minutes, P < .01). There were no significant differences in blood loss, postoperative hospital stays, and the preoperative and postoperative liver function between the two groups (P > .05). Besides, no significant differences were noticed in major clinical characteristics between the 2 groups (P > .05).Liver retraction using NBCA during LC for thick "protrusion" hepatic quadrate lobe patients is safe, effective, and feasible.

Comparison of short-term outcomes between direct anterior approach (DAA) and SuperPATH in total hip replacement: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Two minimally invasive approaches showed some advantages in outcomes compared to conventional approaches (CAs)-the direct anterior approach (DAA) and the supercapsular percutaneously assisted approach in THA (SuperPATH). To the best of our knowledge, DAA and SuperPATH have never been compared, neither in clinical studies, nor in a meta-analysis. To conduct a systematic review and network meta-analysis of randomized controlled trials comparing short-term outcomes of DAA and SuperPATH in total hip joint arthroplasty (THA).

METHODS

A systematic literature search up to May 2020 was performed to identify randomized controlled trials (RCTs) comparing SuperPATH with CAs and DAA with CAs in THA. We measured surgical, functional, and radiological outcomes. A network meta-analysis, using frequentist methods, was performed to assess treatment effects between DAA and SuperPATH. Information was borrowed from the above-mentioned RCTs, using the CA group as a common comparator.

RESULTS

A total of 16 RCTs involving 1392 patients met the inclusion criteria, three trials with a level I evidence, 13 trials with a level II evidence. The overall network meta-analysis showed that SuperPATH reduced operation time (fixed effect model: MD = 12.8, 95% CI 9.9 to 15.7), incision length (fixed effect model: MD = 4.3, 95% CI 4.0 to 4.5; random effect model: MD = 4.3, 95% CI 0.2 to 8.4), intraoperative blood loss (fixed effect model: MD = 58.6, 95% CI 40.4 to 76.8), and early pain intensity (VAS 1 day postoperatively with a fixed effect model: MD = 0.8, 95% CI 0.4 to 1.2). The two approaches did not differ in acetabular cup positioning angles and in functional outcome.

CONCLUSIONS

Our overall findings suggested that the short-term outcomes of THA through SuperPATH were superior to DAA. SuperPATH showed better results in decreasing operation time, incision length, intraoperative blood loss, and early pain intensity. DAA and SuperPATH were equal in functional outcome and acetabular cup positioning.

Systematic Review and Meta-Analysis of the Association Between Non-Steroidal Anti-Inflammatory Drugs and Operative Bleeding in the Perioperative Period

BACKGROUND

It is increasingly recognized that non-opioid analgesia is an important analgesia in the perioperative period. Specifically, NSAIDs (nonsteroidal anti-inflammatory drugs) have been touted as an adjunct, or even replacement, for opioids. However, uptake of NSAIDs has been slow due to concern for side effects, including bleeding. We sought to understand the risk of bleeding caused by NSAIDs in the perioperative period.

STUDY DESIGN

A physician-librarian team performed a search of electronic databases (MEDLINE, EMBASE), using search terms covering the targeted intervention (use of NSAIDs) and outcomes of interest (surgical complications, bleeding), limited to English language articles of any date. We performed a systematic review and meta-analysis of the data.

RESULTS

A total of 2,521 articles were screened, and 229 were selected on the basis of title and abstract for detailed assessment. Including reference searching, 74 manuscripts met inclusion criteria spanning years 1987-2019. These studies included 151,031 patients. Studies included 12 types of NSAIDs, the most common being ketorolac, diclofenac, and ibuprofen, over a wide-range of procedures, from otorhinolaryngology (ENT), breast, abdomen, plastics, and more. More than half were randomized control trials. The meta-analyses for hematoma, return to the operating room for bleeding, and blood transfusions showed no difference in risk in any of 3 categories studied between the NSAID vs non-NSAID groups (p = 0.49, p = 0.79, and p = 0.49, respectively). Quality scoring found a wide range of quality, with scores ranging from lowest quality of 12 to highest quality of 25, out of a total of 27 (average = 16).

CONCLUSIONS

NSAIDs are unlikely to be the cause of postoperative bleeding complications. This literature covers a large number of patients and remains consistent across types of NSAIDs and operations.

Robot-assisted versus laparoscopic minor hepatectomy: A systematic review and meta-analysis

BACKGROUND

Robot-assisted and laparoscopic surgery are the most minimally invasive surgical approaches for the removal of liver lesions. Minor hepatectomy is a common surgical procedure. In this study, we evaluated the advantages and disadvantages of robot-assisted vs laparoscopic minor hepatectomy (LMH).

METHODS

A systematic literature search was performed in PubMed, Embase, and the Cochrane Library to identify comparative studies on robot-assisted vs. laparoscopicminor hepatectomy up to February, 2020. The odds ratios (OR) and mean differences with 95% confidence intervals were calculated using the fixed-effects model or random-effects model.

RESULTS

A total of 12 studies involving 751 patients were included in the meta-analysis. Among them, 297 patients were in the robot-assisted minor hepatectomy (RMH) group and 454 patients were in the LMH group. There were no significant differences in intraoperative blood loss (P = .43), transfusion rates (P = .14), length of hospital stay (P > .64), conversion rate (P = .62), R0 resection rate (P = .56), complications (P = .92), or mortaliy (P = .37) between the 2 groups. However, the RMH group was associated with a longer operative time (P = .0003), and higher cost (P < .00001) compared to the LMH group. No significant differences in overall survival or disease free survival between the 2 groups were observed. In the subgroup analysis of left lateral sectionectomies, RMH was still associated with a longer operative time, but no other differences in clinical outcomes were observed.

CONCLUSIONS

Although RMH is associated with longer operation times and higher costs, it exhibits the same safety and effectiveness as LMH. Prospective randomized controlled clinical trials should now be considered to obtain better evidence for clinical consensus.

Analysis of risk factors for cesarean scar diverticulum: A STROBE-compliant case-control study

ABSTRACT

The purpose of this study was to explore the relevant factors that affect the risk of cesarean scar diverticulum (CSD).A retrospective, case-control study was designed among women with a history of cesarean section (CS) who were admitted in Zhejiang Tongde Hospital from January 2017 to December 2019. Women with missing information were excluded. The basic clinical characteristics and the risk factors for CSD were assessed using univariate analysis and multivariate logistic regression analysis.A total of 216 women were analyzed, including 87 patients with CSD and 129 cases without CSD as control. Significant differences in number of CS, trial of labor (elective or urgent CS), CS interval, uterine position, intraoperative hemorrhage, and dysmenorrhea between CSD group and control group (P < .05). Multivariate logistic regression analysis showed that number of CS, trial of labor, interval of CS, and uterine position were independent risk factors of CSD.In women with a history of CS, multiple cesarean deliveries, elective CS, cesarean interval of less than 5 years, and retroflexed position of the uterus may be associated with an elevated risk of CSD.

Prophylactic temporary abdominal aortic balloon occlusion for patients with pernicious placenta previa: a retrospective study

BACKGROUND

Pernicious placenta previa (PPP) can increase the risk of perioperative complications. During caesarean section in patients with adherent placenta, intraoperative blood loss, hysterectomy rate and transfusion could be reduced by interventional methods. Our study aimed to investigate the influence of maternal hemodynamics control and neonatal outcomes of prophylactic temporary abdominal aortic balloon (PTAAB) occlusion for patients with pernicious placenta previa.

METHODS

This was a retrospective study using data from the Peking University People's Hospital from January 2014 through January 2020. Clinical records of pregnant women undergoing cesarean section were collected. Patients were divided into two groups: treatment with PTAAB placement (group A) and no balloon placement (group B). Group A was further broken down into two groups: prophylactic placement (Group C) and balloon occlusion (group D).

RESULTS

Clinical records of 33 cases from 5205 pregnant women underwent cesarean section were collected. The number of groups A, B, C, and D were 17, 16, 5 and 12.We found that a significant difference in the post-operative uterine artery embolism rates between group A and group B (0% vs.31.3%, p = 0.018). There was a significant difference in the Apgar scores at first minute between group A and group B (8.94 ± 1.43 vs 9.81 ± 0.75,p = 0.037),and the same significant difference between two groups in the pre-operative central placenta previa (29.4% vs. 0%,p = 0.044), complete placenta previa (58.8% vs 18.8%, p = 0.032),placenta implantation (76.5% vs 31.3%, p = 0.015). We could also observe the significant difference in the amount of blood cell (2.80 ± 2.68vs.10.66 ± 11.97, p = 0.038) and blood plasma transfusion (280.00 ± 268.32 vs. 1033.33 ± 1098.20, p = 0.044) between group C and group D. The significant differences in the preoperative vaginal bleeding conditions (0% vs 75%, p = 0.009), the intraoperative application rates of vasopressors (0% vs. 58.3%, p = 0.044) and the postoperative ICU (intensive care unit) admission rates (0% vs. 58.3%, p = 0.044) were also kept.

CONCLUSIONS

PTAAB occlusion could be useful in reducing the rate of post-operative uterine artery embolism and the amount of transfusion, and be useful in coping with patients with preoperative vaginal bleeding conditions, so as to reduce the rate of intraoperative applications of vasopressors and the postoperative ICU (intensive care unit) admission. In PPP patients with placenta implantation, central placenta previa and complete placenta previa, we advocate the utilization of prophylactic temporary abdominal aortic balloon placement.

Open and/or laparoscopic one-stage resections of primary colorectal cancer and synchronous liver metastases: An observational study

One-stage resections of primary colorectal cancer and liver metastases have been reported to be feasible and safe. Minimally invasive approaches have become more common for both colorectal and hepatic surgeries. This study aimed to investigate outcomes of these combined surgical procedures among different approaches.We retrospectively analyzed patients diagnosed as having primary colorectal cancer with synchronous liver metastases and who underwent 1-stage primary resection and hepatectomy with curative intent in our hospital. According to the surgical approach for the primary tumor and hepatic lesions, namely open laparotomy (Op) or laparoscopic approach (Lap), patients were classified into Op-Op, Lap-Op (laparoscopic colorectal resection plus open hepatectomy), and Lap-Lap groups, respectively. Clinicopathological factors were reviewed, and short- and long-term outcomes were compared among the groups.The Op-Op, Lap-Op, and Lap-Lap groups comprised 36, 18, and 17 patients, respectively. The superior/posterior hepatic segments were more frequently resected via an open approach. There was no laparoscopic major hepatectomy. The median volume of intraoperative blood loss was smaller in the Lap-Lap and Lap-Op groups (290 and 270 mL) than in the Op-Op group (575 mL, P = .008). The hospital stay after surgery was shorter in the Lap-Lap and Lap-Op groups (median: 17 days and 15 days, vs 19 days for the Op-Op group, P = .033). The postoperative complication rates and survivals were similar among the groups.Application of laparoscopy to 1-stage resections of primary colorectal cancer and liver metastases may offer advantages of enhanced recovery from surgical treatment, given appropriate patient selection.

Clinical effectiveness of arthroscopic vs open ankle arthrodesis for advanced ankle arthritis: A systematic review and meta-analysis

BACKGROUND

Ankle fusion is the primary treatment for advanced ankle arthritis. With the advancement of arthroscopy technology, ankle arthroscopy fusion has shown many advantages over traditional surgery. However, there are few related studies globally, and evidence-based medicine is needed to verify the reliability and feasibility of ankle arthroscopy fusion.

OBJECTIVE

To compare the clinical efficacy and safety of arthroscopic ankle arthrodesis and open ankle arthrodesis.

METHODS

We searched the databases of PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure [CNKI], Wanfang Database, and VIP Database for published prospective or retrospective controlled studies of arthroscopic-assisted ankle fusion in the treatment of advanced ankle arthritis. The dates were limited from the construction of the library to June 30, 2019. Literature was included based on the principles and methods of evidence-based medicine. Literature retrieval, data extraction, and quality assessment were performed by 2 independent reviewers using the Cochrane 5.1 risk bias assessment tool. The methodological bias of the literature was evaluated, and a meta-analysis was using by RevMan 5.3 software.

RESULTS

A total of 18 studies and 1102 patients were included in the study, including 551 in the arthroscopic surgery group and 551 in the open surgery group. Arthroscopy-assisted surgery for advanced ankle arthritis was more effective than open surgery in terms of fusion rate (odd ratio[OR] = 3.32, 95% confidence interval[CI]:2.16, 5.10), fusion time (mean difference[MD] = -2.31, 95% CI:-4.63, -2.21), intraoperative blood loss (MD = -43.37, 95%CI: -48.49, -38.25), hospital stay (MD = -1.80, 95%CI: -2.28, -1.33), and visual analog scale score (MD = -1.75, 95%CI: -2.04, -1.46). In addition, rate of complications (OR = 0.33, 95%CI: 0.21, 0.52) was superior to open ankle fusion (P < .00001).

CONCLUSION

Arthroscopic ankle arthrodesis has more advantages than open ankle arthrodesis in improving the fusion rate and reducing complications, which is worthy of clinical application.

PROSPERO REGISTRATION NUMBER

CRD42020195727.

Comparison of clinical outcomes with hip replacement versus PFNA in the treatment of intertrochanteric fractures in the elderly: A systematic review and meta-analysis (PRISMA)

BACKGROUND

The purpose of this meta-analysis was to evaluate the clinical efficacy and safety of HR and PFNA in the treatment of intertrochanteric fractures in the elderly.

METHODS

We carried out this review according to the principle of preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline. The clinical randomized controlled trials (RCTs), prospective cohort studies, retrospective cohort studies (RCSs), and case-control studies involving HR and PFNA in the treatment of intertrochanteric fractures in the elderly from 2000 to 2020 were compared by searching Web of Science, Pubmed, the Cochrane Library, and Embase. The quality of the included cohort study (CS) lines was evaluated using the Newcastle-Ottawa Scale (NOS). The quality of the included RCT lines was evaluated using Jadad. Forest plots were drawn by RevMan5.4 software based on the results and the data were analyzed.

RESULTS

After screening, a total of 9 articles were included, of which one was a clinical RCT and eight were RCSs with 1374 patients. The operative time of the PFNA group was shorter [WMD = 15.20; 95% CI (13.17, 17.23), P < .05] and the intraoperative blood loss was less [WMD = 178.81; 95% CI (97.24, 260.38), P < .05] than the HR group, while the first weight-bearing time of the HR group was shorter [WMD = -7.70; 95% CI (-10.54, -4.86), P  < .05] than the PFNA group. There was no significant difference in the length of hospital stay, HHS, postoperative orthopedic complications, and postoperative medical complications between the 2 groups.

CONCLUSION

With the development of HR technology and minimally invasive technology, the trauma caused by surgery is decreasing. Under the premise of improving perioperative management, such as optimizing the preoperative preparation and postoperative management, shortening the operative time, reducing intraoperative blood loss, and actively managing co-existing diseases, HR has more advantages than PFNA in the treatment of senile intertrochanteric fractures.

Evaluating Tourniquet Efficacy Comparing Exsanguination Techniques for the Upper Extremity

Tourniquets have been used in the medical setting for centuries and have become the gold standard when preparing patients for surgery, particularly in orthopaedic surgery. Upper extremity tourniquet use improves intraoperative visibility and identification of anatomy. It also decreases blood loss intraoperatively and improves the safety of orthopaedic procedures. Despite the widespread use of tourniquets and differing methods of limb exsanguination, little research has been done quantifying its efficacy. The purpose of this study was to compare gravity exsanguination to Esmarch exsanguination of the upper extremity prior to tourniquet inflation in a large patient sample. A plethysmographic method based on water displacement served as a surrogate for the blood volume exsanguinated. Control measurements of water displacement were obtained from both upper extremities without tourniquet inflation. Water displacement was then measured with both gravity and Esmarch exsanguination techniques. Gender, handedness, height, weight, body mass index, and age were recorded for volunteers and used as covariates. Change in mean water displacement from control (un-exsanguinated) arm and gravity alone measurement was 37.2 ml. Change in mean water displacement between control arm and mean Esmarch measurement was 56.3 ml. Exsanguination using Esmarch compared to gravity alone resulted in a 51.2% increase in blood removal. Only age had a significant interaction effect for the Esmarch method. Analysis revealed that age accounted for 21.4% of all variance in blood exsanguinated using the Esmarch method when compared to the control group. The Esmarch technique was more efficacious for all demographics measured, but most efficacious in subjects who were older than 40 years. This data reaffirms that gravity exsanguination is more efficacious than no tourniquet use at all, and that the Esmarch technique is more efficacious than gravity. To our knowledge, this study is the most robust of its kind to critically and objectively compare upper extremity exsanguination methods and overall tourniquet use by age and supports the common practice of Esmarch exsanguination in orthopaedic extremity surgery.

Correlation of An Ultrasonic Scoring System and Intraoperative Blood Loss in Placenta Accreta Spectrum Disorders: A Retrospective Cohort Study

OBJECTIVE

This study aims to investigate the correlation of an ultrasonic scoring system with intraoperative blood loss (IBL) in placenta accreta spectrum (PAS) disorders.

METHODS

A retrospective cohort study was conducted between January 2015 and November 2019. Clinical data for patients with PAS have been obtained from medical records. Generalized additive models were used to explore the nonlinear relationships between ultrasonic scores and IBL. Logistic regressions were used to determine the differences in the risk of IBL ≥ 1,500 mL among groups with different ultrasonic scores.

RESULTS

A total of 332 patients participated in the analysis. Generalized additive models showed a significant positive correlation between score and blood loss. The amount of IBL was increased due to the rise in the ultrasonic score. All cases were divided into three groups according to the scores (low score group: ≤ 6 points, n = 147; median score group: 7-9 points, n = 126; and high score group: ≥ 10 points, n = 59). Compared with the low score group, the high score group showed a higher risk of IBL ≥ 1,500 mL [odds ratio, 15.09; 95% confidence interval (3.85, 59.19); P ≤ 0.001] after a multivariable adjustment.

CONCLUSIONS

The risk of blood loss equal to or greater than 1,500 mL increases further when ultrasonic score greater than or equal to 10 points, the preparation for transfusion and referral mechanism should be considered.

Comparison of clinical efficacy of laparoscopic splenectomy versus open splenectomy for idiopathic thrombocytopenic purpura: A meta-analysis

BACKGROUND

The purpose of this study is to compare the clinical efficacy of laparoscopic splenectomy (LS) and open splenectomy (OS) in the treatment of Idiopathic thrombocytopenic purpura.

METHODS

We systematically searched PubMed, Web of science, EMBASE, Clinicaltrials.gov, and Cochrane Central Register for studies (study published from July 1992-January 2020). This study analyzed the clinical effect of LS and OS on idiopathic thrombocytopenic purpur.

RESULTS

This study showed that compared with OS, the LS's Overall response (OR: 0.60, 95% confidence interval (CI): 0.23-1.59, P = .30), Complication (OR: 0.59, 95% CI: 0.18-1.94, P = .38), Accessory spleen(OR: 1.70, 95% CI: 0.98-2.98, P = .06), Wound infections (OR: 0.65, 95% CI: 0.26-1.59, P = .34), Pancreatic fistula (OR: 0.73, 95% CI: 0.16-3.30, P = .68), was no significant, the Operative time (weighted mean difference (WMD): 49.33, 95% CI: 36.29-62.37, P < .00001)was longer, and the Estimated blood loss (WMD: -172.59, 95% CI: -319.96 to -25.22, P = .02), Postoperative length of stay (WMD: -4.68, 95% CI: -7.75 to -1.62, P = .003)was less.

CONCLUSIONS

The therapeutic effect of LS was the same as that of OS in Overall response Complication Accessory spleen, while The operative time was longer, the Estimated blood loss was less, and the postoperative length of stay was shorter.

Safety and feasibility of laparoscopic gastrectomy for remnant gastric cancer compared with open gastrectomy: Single-center experience

The usefulness, safety and oncological validity of laparoscopic gastrectomy (LG) for remnant gastric cancer (RGC) have not been widely reported.A total of 38 patients who underwent gastrectomy for RGC were enrolled at Wakayama Medical University Hospital between April 2008 and December 2018. All consecutive patients were included in this retrospective study; the patients were divided into the open gastrectomy group and the laparoscopic group according to the sequential nature of their operation. Fifteen patients underwent open gastrectomy for RGC (OGR) between April 2008 and December 2013, and 23 patients underwent LG for RGC (LGR) after 2014.In the OGR group, all initial operations were performed by open surgery, whereas in the LGR group, 11 patients (47%) initially underwent laparoscopic surgery and 12 patients (53%) initially underwent open surgery (P = .002), 3 patients of which (25%) converted to open gastrectomy. There was no significant difference in the number of lymph node dissections or in operative time between the 2 groups, but blood loss was significantly lower in the LGR group than that in the OGR group (P = .002). Furthermore, although there was no difference between the 2 groups in C-reactive protein value on postoperative day 1, C-reactive protein value on postoperative day 3 was significantly lower in the LGR group than in the OGR group (P = .012). There were no differences in postoperative complications or long-term outcomes, including recurrence-free survival and overall survival.LGy is suitable in cases in which the initial surgery is performed by laparoscopic surgery. Even if the initial surgery is open surgery, it is oncologically equivalent to open gastrectomy and can be performed safely with less blood loss.

Is stand-alone lateral lumbar interbody fusion superior to instrumented lateral lumbar interbody fusion for the treatment of single-level, low-grade, lumbar spondylolisthesis?

BACKGROUND

The aim of this study was to compare surgical trauma and radiographic and clinical outcomes of stand-alone and instrumented lateral lumbar interbody fusion (LLIF) in the treatment of single-level low-grade lumbar spondylolisthesis.

METHODS

Ninety-five patients with single-level low-grade lumbar spondylolisthesis, who underwent stand-alone LLIF (stand-alone group, [n = 54]) or LLIF plus percutaneous posterior fixation (instrumented group, [n = 41]) were enrolled in this study. Operative time, intraoperative blood loss, serum C-reactive protein (CRP) and creatine kinase (CK) levels, the length of postoperative bed rest time, and hospital stay were compared between the 2 groups. Disc height, the percent of slip, segment lordosis, lumbar lordosis, the visual analog scale score, the Oswestry Disability Index and complications were also compared.

RESULTS

Operative and bed rest time were shorter, intraoperative blood loss was less, and postoperative CRP and CK levels were lower in the stand-alone group. During follow-up, 6 patients in stand-alone group underwent posterior fixation due to cage subsidence. Although satisfactory radiographic results were achieved in both groups, the maintenance of increased disc heights and segment lordosis was inferior in the stand-alone group at the final follow-up. Greater improvement in postoperative VAS scores and ODI were observed in the stand-alone group, although the rates of cage subsidence and revision were higher.

CONCLUSION

Stand-alone LLIF was superior to instrumented LLIF in terms of tissue trauma for the treatment of single-level low-grade lumbar spondylolisthesis. However, stand-alone LLIF was inferior in the maintenance of disc height and segment lordosis, and the occurrence of cage subsidence and revision.

Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes

INTRODUCTION

The role of tourniquet during knee arthroplasty is controversial. The present study compares various tourniquet protocols using a Bayesian network meta-analysis of peri-operative data.

MATERIAL AND METHODS

The present study was conducted in accordance with the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health interventions. The literature search was conducted in September 2020. All clinical trials investigating the role of tourniquet in knee arthroplasty were considered for inclusion. Methodological quality was assessed using Review Manager 5.3. A Bayesian hierarchical random-effects model analysis was used in all comparisons.

RESULTS

Ultimately, pooled data from 68 studies (7413 procedures) were analysed. Significant inconsistency was found in the data relating to total estimated blood lost; no assumption could be made on this outcome. Full-time tourniquet resulted in the shortest surgical duration and lowest intra-operative blood lost, in both cases followed by incision-to-suture. The incision-to-suture protocol achieved the smallest drop in haemoglobin during the first 72 h post-operatively and the lowest rate of blood transfusion, both followed by full-time tourniquet. Hospitalisation was shortest in the absence (no-tourniquet) group, followed by the cementation-to-end group.

CONCLUSION

For knee arthroplasty, longer tourniquet use is associated with the shorter duration of surgery, lower intra-operative blood lost, lower drops in haemoglobin and fewer transfusion units. The shortest average hospitalisation was associated with no tourniquet use.

Blood loss from transverse versus longitudinal uterine incision in abdominal myomectomy: a randomized controlled trial

BACKGROUND

It is unclear whether transverse uterine incision is non-inferior to longitudinal incision during myomectomy with regard to bleeding. Our aim was to compare between transverse and longitudinal uterine incisions in myomectomy.

METHODS

A parallel randomized controlled single-blinded study in a university affiliated hospital, in the period between January 2017 and April 2018, in which 52 women candidates for abdominal myomectomy were randomized into transverse uterine incision or longitudinal uterine incision groups (26 in each group). Intraoperative blood loss (estimated directly by blood volume in suction bottle and linen towels and indirectly by difference between preoperative and postoperative hematocrit), operative time and postoperative fever were analyzed.

RESULTS

No statistically significant difference was found between transverse and longitudinal incisions regarding intraoperative blood loss (389.7 ± 98.56 ml vs 485.04 ± 230.6 ml respectively, p value = 0.07), operative time (59.96 ± 16.78 min vs 66.58 ± 17.33 min respectively, p value = 0.18), and postoperative fever (4% vs 8.33%, p value = 0.6).

CONCLUSION

Transverse uterine incision does not cause more blood loss than longitudinal incision and is a reasonable option during abdominal myomectomy.

TRIAL REGISTRATION

NCT03009812 at clinicaltrials.gov, registered January 2017.

Clips Can be Safely Used for Vascular Control of the Renal Vessels During Laparoscopic Donor Nephrectomy

OBJECTIVE

To review our experience using clips to control the renal vessels during laparoscopic donor nephrectomy (LDN) and determine the safety of this practice.

METHODS

We performed a retrospective review of patients who underwent LDN at our centre January 1, 2007-September 17, 2019. The primary outcome was the rate of complication associated with vascular control of the renal vessels, which included (1) conversion to open to manage bleeding, (2) additional procedures for bleeding, and (3) major bleeding requiring blood transfusion. Secondary outcomes included the rate of renal artery/vein clip dislodgement or crossing, change in hemoglobin, warm ischemia time and the incidence of intra-operative complications and postoperative in-hospital complications.

RESULTS

We included 503 patients who underwent LDN, of which 497 were left sided. The main renal artery was controlled with 3 titanium clips in 489 (97%) cases. The main renal vein was controlled with 2 polymer-locking clips in 478 (95%) cases. For our primary outcome, there were no conversions to open to manage bleeding, no secondary procedures due to bleeding and no major bleeding requiring blood transfusion. Additionally, there were no donor deaths. Regarding our secondary outcomes, there were 5 intraoperative events related to the titanium clips being placed on the renal artery and 1 intraoperative event related to the polymer-locking clips on the renal vein, none of which resulted in any morbidity.

CONCLUSION

Using 3 titanium clips on the renal artery and 2 polymer-locking clips on the renal vein during left LDN is safe and provides excellent vascular control.

Laparoscopic versus open distal gastrectomy for advanced gastric cancer: A meta-analysis of randomized controlled trials and high-quality nonrandomized comparative studies

BACKGROUND

Controversy persists about the effects of laparoscopic distal gastrectomy (LDG) versus open distal gastrectomy (ODG) on short-term surgical outcomes and long-term survival within the field of advanced gastric cancer (AGC).

METHODS

Studies published from January 1994 to February 2020 that compare LDG and ODG for AGC were identified. All randomized controlled trials (RCTs) were included. The selection of high-quality nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies, MINORS). The short- and long-term outcomes of both procedures were compared.

RESULTS

Overall, 30 studies were included in this meta-analysis, which comprised of 8 RCTs and 22 NRCTs involving 16,029 patients (7864 LDGs, 8165 ODGs). The recurrence, 3-year disease-free survival (DFS), 3-year overall survival (OS), and 5-year OS rates for LDG and ODG were comparable. LDG was associated with a lower postoperative complication rate (OR 0.79; P < 0.00001), lower estimated volume of blood loss (WMD -102.21 mL; P < 0.00001), shorter postoperative hospital stay (WMD -1.96 days; P < 0.0001), shorter time to first flatus (WMD -0.54 day; P = 0.0007) and shorter time to first liquid diet (WMD -0.66 day; P = 0.001). The number of lymph nodes retrieved, mortality, intraoperative complications, intraoperative blood transfusion, and time to ambulation were similar. However, LDG was associated with a longer surgical time (WMD 33.57 min; P < 0.00001).

CONCLUSIONS

LDG with D2 lymphadenectomy is a safe and effective technique for patients with AGC when performed by experienced surgeons at high-volume specialized centers.

The effect of an oxytocin washout period on blood loss at cesarean delivery

Objectives Prolonged oxytocin exposure may result in increased blood loss during delivery. Our objective was to determine whether an oxytocin rest period before cesarean delivery had an impact on blood loss. Methods We performed a retrospective cohort study of women who underwent primary cesarean delivery after oxytocin augmentation. The primary outcome was change between pre- and postoperative hematocrit (Hct) in women with less than 60-min oxytocin rest period (<60 min) and greater than 60-min rest period (>60 min). Results There was no difference in demographic characteristics (age, BMI, or gestational age at delivery) between the two groups. Women in the >60 min group had a higher cumulative dose and longer duration of oxytocin administration. There was no significant difference in change in Hct between the two groups when controlling for these factors. Conclusions We did not find a significant correlation between the duration of the oxytocin rest period and blood loss. Oxytocin washout periods of greater than 60 min may not result in decreased blood loss at cesarean delivery, and thus, women may not benefit from such oxytocin washout periods.

Comparative clinical outcomes of robot-assisted liver resection versus laparoscopic liver resection: A meta-analysis

BACKGROUND

As an emerging technology, robot-assisted surgical system has some potential merits in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted liver resection is still a controversial problem on its advantages compared with laparoscopic liver resection. We aimed to perform the meta-analysis to assess and compare the clinical outcomes of robot-assisted and laparoscopic liver resection.

METHODS

We searched PubMed, Cochrane Library, Embase databases, Clinicaltrials, and Opengrey through March 24, 2020, including references of qualifying articles. English-language, original investigations in humans about robot-assisted and laparoscopic hepatectomy were included. Titles, abstracts, and articles were reviewed by at least 2 independent readers. Continuous and dichotomous variables were compared by the weighted mean difference (WMD) and odds ratio (OR), respectively.

RESULTS

Of 936 titles identified in our original search, 28 articles met our criteria, involving 3544 patients. Compared with laparoscopy, the robot-assisted groups had longer operative time (WMD: 36.93; 95% CI, 19.74-54.12; P < 0.001), lower conversion rate (OR: 0.63; 95% CI, 0.46-0.87; P = 0.005), higher transfusion rate (WMD: 2.39; 95% CI, 1.51-3.76; P < 0.001) and higher total cost (WMD:0.49; 95% CI, 0.42-0.55; P < 0.001). In addition, the baseline characteristics of patients about largest tumor size was larger (WMD: 0.36; 95% CI, 0.16-0.56; P < 0.001) and malignant lesions rate was higher (WMD: 1.50; 95% CI, 1.21-1.86; P < 0.001) in the robot-assisted versus laparoscopic hepatectomy. The subgroup analysis of minor hepatectomy showed robot-assisted was associated with longer operative time (WMD: 36.00; 95% CI, 12.59-59.41; P = 0.003), longer length of stay (WMD: 0.51; 95% CI, 0.02-1.01; p = 0.04) and higher total cost (WMD: 0.48; 95% CI, 0.25-0.72; P < 0.001) (Table 3); while the subgroup analysis of major hepatectomy showed robot-assisted was associated with lower estimated blood loss (WMD: -122.43; 95% CI, -151.78--93.08; P < 0.001).

CONCLUSIONS

Our meta-analysis revealed that robot-assisted was associated with longer operative time, lower conversion rate, higher transfusion rate and total cost, and robot-assisted has certain advantages in major hepatectomy compared with laparoscopic hepatectomy.

Determining the protective characteristics and risk factors for the development of anastomotic leakage after low anterior resection for rectal cancer

Purpose

Anastomotic leakage is one of the most serious postoperative complications associated with surgery for rectal cancer. The present study aimed to identify the protective characteristics and risk factors associated with anastomotic leakage after low anterior resection for rectal cancer.

Methods

This was a retrospective, single-center study conducted between January 2009 and December 2017 at our institution. In total, 136 rectal cancer patients who underwent low anterior resection were included in the study. We analyzed preoperative and intraoperative factors. In addition, the pelvic dimensions were measured using computed tomography in all cases.

Results

Among the 136 patients, anastomotic leakage occurred in 21 (15.4%), including 18 males and 3 females. The median body mass index was 21.1 kg/m². The construction of a covering stoma was found to be a protective factor. In addition, the operation time (≥ 373 min), intraoperative blood loss (≥ 105 ml), and size of the pelvic inlet (≥ 113 mm) were identified as risk factors for anastomotic leakage.

Conclusion

The construction of a covering stoma was a possible protective factor. However, a longer operation time, higher intraoperative blood loss, and larger pelvic inlet dimensions were possible risk factors for developing anastomotic leakage after low anterior resection in patients with rectal cancer.

Bleeding After Musculoskeletal Surgery in Hospitals That Switched From Hydroxyethyl Starch to Albumin Following a Food and Drug Administration Warning

BACKGROUND

While US Food and Drug Administration (FDA) black box warnings are common, their impact on perioperative outcomes is unclear. Hydroxyethyl starch (HES) is associated with increased bleeding and kidney injury in patients with sepsis, leading to an FDA black box warning in 2013. Among patients undergoing musculoskeletal surgery in a subset of hospitals where colloid use changed from HES to albumin following the FDA warning, we examined the rate of major perioperative bleeding post- versus pre-FDA warning.

METHODS

The authors of this article used a retrospective, quasi-experimental, repeated cross-sectional, interrupted time series study of patients undergoing musculoskeletal surgery in hospitals within the Premier Healthcare Database, in the year before and year after the 2013 FDA black box warning. We examined patients in 23 "switcher" hospitals (where the percentage of colloid recipients receiving HES exceeded 50% before the FDA warning and decreased by at least 25% in absolute terms after the FDA warning) and patients in 279 "nonswitcher" hospitals. Among patients having surgery in "switcher" and "nonswitcher" hospitals, we determined monthly rates of major perioperative bleeding during the 12 months after the FDA warning, compared to 12 months before the FDA warning. Among patients who received surgery in "switcher" hospitals, we conducted a propensity-weighted segmented regression analysis assessing differences-in-differences (DID), using patients in "nonswitcher" hospitals as a control group.

RESULTS

Among 3078 patients treated at "switcher" hospitals (1892 patients treated pre-FDA warning versus 1186 patients treated post-FDA warning), demographic and clinical characteristics were well-balanced. Two hundred fifty-one (13.3%) received albumin pre-FDA warning, and 900 (75.9%) received albumin post-FDA warning. Among patients undergoing surgery in "switcher" hospitals during the pre-FDA warning period, 282 of 1892 (14.9%) experienced major bleeding during the hospitalization, compared to 149 of 1186 (12.6%) following the warning. In segmented regression, the adjusted ratio of slopes for major perioperative bleeding post- versus pre-FDA warning was 0.98 (95% confidence interval [CI], 0.93-1.04). In the DID estimate using "nonswitcher" hospitals as a control group, the ratio of ratios was 0.93 (95% CI, 0.46-1.86), indicating no significant difference.

CONCLUSIONS

We identified a subset of hospitals where colloid use for musculoskeletal surgery changed following a 2013 FDA black box warning regarding HES use in sepsis. Among patients undergoing musculoskeletal surgery at these "switcher" hospitals, there was no significant decrease in the rate of major perioperative bleeding following the warning, possibly due to incomplete practice change. Evaluation of the impact of systemic changes in health care may contribute to the understanding of patient outcomes in perioperative medicine.

Blood loss in primary total hip arthroplasty with a short versus conventional cementless stem: a retrospective cohort study

INTRODUCTION

To evaluate the impact of short cementless stem on several clinical and radiographic outcomes, with particular focus on blood loss, in comparison with conventional cementless stem in total hip arthroplasty (THA).

MATERIALS AND METHODS

Patients undergoing THA with GTS short stem or CLS conventional stem were included. Clinical data were retrospectively collected including preoperative and postoperative day 1 value for haemoglobin (HB); rate of postoperative blood transfusions; intraoperative bone infractions; stem alignment; 5-year follow-up Harris Hip Score (HHS) and rate of stem revision at 5 years of follow-up of the short and conventional cementless stem.

RESULTS

GTS and CLS stem group included 374 and 321 patients, respectively. The mean difference between the preoperative and postoperative day 1 HB value was 3.98 g/dL (SD 1.12) and 3.67 g/dL (SD 1.19) in the GTS and CLS group, respectively, which correspond to a crude effect (β) of 0.32 (95% CI 0.15; 0.49) and adjusted effect of 0.11 (95% CI - 0.08; 0.3). GTS group reported a significantly higher number of patients with excellent results in terms of HHS (p = 0.001). The rate of intraoperative bone infractions was 1.6% and 0.3% in the GTS and CLS group, respectively (p = 0.013). At radiographic assessment, the rate of varus position of the stem was 14% in the GTS group and 6% in the CLS group (p < 0.0001). The rate of stem revision at 5 years of follow-up was 0.8% and 0.4% in the GTS and CLS group, respectively (p = 0.63).

CONCLUSIONS

GTS short stem was not associated with a clinically significant lower blood loss in the immediately postoperative period. Unadjusted exploratory analyses show that GTS stem provides the same results of CLS stem in terms of HHS and rate of stem revision at 5 years of follow-up.