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Lapisatepun W, Pipanmekaporn T, Leurcharusmee P, Khorana J, Patumanond J, Lapisatepun W. Development of the liver resection transfusion (LiReT) score to assess the requirement for blood transfusion during open liver surgery. HPB (Oxford) 2025:S1365-182X(25)00551-9. [PMID: 40287298 DOI: 10.1016/j.hpb.2025.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 11/20/2024] [Accepted: 04/07/2025] [Indexed: 04/29/2025]
Abstract
BACKGROUND Liver resection involves significant perioperative bleeding and blood transfusions, which may worsen outcomes. Blood products are scarce, and excessive preoperative cross-matching can deplete the blood supply. This study aimed to develop a clinical prediction score to assess the need for perioperative blood transfusions during liver resection. METHODS We conducted a retrospective cohort study using data from patients who underwent liver resections between 2006 and 2021. Independent predictors and a scoring system were analyzed using multivariable logistic regression. The model's effectiveness was assessed by the area under the ROC curve (AuROC) and calibration plots, with internal validation. RESULT Among 1021 patients, 456 (44.7%) required perioperative blood transfusions. Eight predictors were identified: ASA classification >2, preoperative anemia, platelet count <100 × 109/L, albumin <3.5 g/dL, total bilirubin >1.2 mg/dL, GFR <60 ml/min/1.73 m², maximum tumor diameter ≥5 cm, and major liver resection. The LiReT score categorized patients into low, moderate, and high-risk groups and showed good discriminative ability with an AuROC of 0.808 and good calibration. CONCLUSION The LiReT score, with its good predictive accuracy, can guide clinicians in assessing perioperative blood transfusion risk, optimizing cross-matching and resource utilization, and facilitating patient blood management strategies during liver resection.
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Affiliation(s)
| | - Tanyong Pipanmekaporn
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University; Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University
| | | | - Jiraporn Khorana
- Department of Surgery, Faculty of Medicine, Chiang Mai University; Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University
| | - Jayanton Patumanond
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University
| | - Worakitti Lapisatepun
- Department of Surgery, Faculty of Medicine, Chiang Mai University; Clinical Surgical Research Center, Chiang Mai University, Thailand.
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Oliva JG, Prado CA, de Assis GL, Figueiredo GA, Ribeiro LV, Porto MA, Duarte MF, Ribeiro NN, Silva VF, Coelho ER. Hypovolemic Phlebotomy in Hepatic Surgeries: Systematic Review and Updated Meta-Analysis of Blood Loss Reduction and Perioperative Outcomes. Cureus 2025; 17:e81879. [PMID: 40342460 PMCID: PMC12060582 DOI: 10.7759/cureus.81879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2025] [Indexed: 05/11/2025] Open
Abstract
Hepatic resection, especially in major procedures, is associated with high perioperative morbidity, primarily due to the significant risk of intraoperative hemorrhage and the consequent need for blood transfusions, factors that negatively impact clinical outcomes. Strategies to mitigate blood loss include hypovolemic phlebotomy (HP), a technique characterized by the controlled removal of a blood volume before liver transection, without immediate volume replacement, aiming to reduce central venous pressure (CVP) and consequently minimize intraoperative bleeding. Initial evidence suggests that HP may reduce the need for transfusions and improve the preservation of residual liver function, although its efficacy and safety still need to be validated in clinical studies with greater methodological robustness. This systematic review and meta-analysis aimed to assess the efficacy of hypovolemic phlebotomy in reducing blood loss during liver resections and improving perioperative outcomes. This meta-analysis was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). To build the evidence base, a search was conducted in electronic databases, including PubMed, EMBASE, and the Cochrane Library, covering publications between 2010 and 2025. The risk of bias assessment was performed using RoB 2 for randomized clinical trials (RCTs) and ROBINS-I for observational studies. Statistical analysis was conducted using Review Manager 5.4. For binary variables, risk ratio (RR) was used, while for continuous variables, mean difference (MD) was applied in outcome analysis. Cochran's Q test and Higgins' I² were used to assess heterogeneity among studies. Two RCTs and five observational studies were included, combining 3,369 patients undergoing liver surgery, with 1,759 (52.22%) in the HP group and 1,610 (47.78%) in the control group. HP was associated with a significant reduction in intraoperative blood loss (MD = -52.29; 95% CI -68.81 to -37.77; P < 0.00001). Additionally, there was a decrease in the need for intraoperative transfusion (RR = 0.27; 95% CI 0.19 - 0.38; P < 0.00001) and perioperative transfusion (RR = 0.43; 95% CI 0.28 - 0.66; P = 0.0001). Hospital length of stay showed no significant difference between groups (MD = -0.29; 95% CI -0.79 - 0.21; P = 0.26), nor did the analysis of major complications (Clavien-Dindo ≥ 3), which also did not demonstrate a statistically significant difference (RR = 0.94; 95% CI 0.72-1.24; P = 0.68). In conclusion, HP demonstrated significant outcomes in liver surgeries, particularly in reducing intraoperative blood loss and the need for intraoperative and postoperative blood transfusions. Furthermore, the technique showed no significant difference in hospital length of stay, incidence of severe complications, or other clinical outcomes. Therefore, larger randomized studies are needed to determine the real impact of HP in different surgical settings.
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Affiliation(s)
- João G Oliva
- Department of Life Sciences, State University of Bahia (UNEB), Salvador, BRA
| | - Clara A Prado
- General Surgery, Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, BRA
| | | | | | - Lucas V Ribeiro
- General Surgery, Salvador University (UNIFACS), Salvador, BRA
| | - Maria A Porto
- General Surgery, Salvador University (UNIFACS), Salvador, BRA
| | | | - Natália N Ribeiro
- General Surgery, Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, BRA
| | - Victor F Silva
- General Surgery, Salvador University (UNIFACS), Salvador, BRA
| | - Elaine R Coelho
- Digestive System Surgery, Roberto Santos General Hospital, Salvador, BRA
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Catalano G, Alaimo L, Endo Y, Chatzipanagiotou OP, Ruzzenente A, Aldrighetti L, Weiss M, Bauer TW, Alexandrescu S, Poultsides GA, Maithel SK, Marques HP, Martel G, Pulitano C, Shen F, Cauchy F, Koerkamp BG, Endo I, Kitago M, Pawlik TM. Development and Validation of a Predictive Risk Score for Blood Transfusion in Patients Undergoing Curative-Intent Surgery for Intrahepatic Cholangiocarcinoma. J Surg Oncol 2025; 131:242-251. [PMID: 39285653 PMCID: PMC12035667 DOI: 10.1002/jso.27903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2024] [Accepted: 08/30/2024] [Indexed: 04/29/2025]
Abstract
BACKGROUND AND OBJECTIVES Among patients undergoing liver resection for intrahepatic cholangiocarcinoma (ICC), perioperative bleeding requiring blood transfusion is a common complication, yet preoperative identification of patients at risk for transfusion remains challenging. The objective of this study was to develop a preoperative risk score for blood transfusion requirement during surgery for ICC. METHODS Patients undergoing curative-intent liver surgery for ICC (1990-2020) were identified from a multi-institutional database. A predictive model was developed and validated. An easy-to-use risk calculator was made available online. RESULTS Among 1420 patients, 300 (21.1%) received an intraoperative transfusion. Independent predictors of transfusion included severe preoperative anemia (OR = 1.65, 95% CI 1.10-2.47), T2 category or higher (OR = 2.00, 95% CI 1.36-3.02), positive lymph nodes (OR = 1.75, 95% CI 1.32-2.32) and major resection (OR = 2.56, 95%CI 1.85-3.58). Receipt of blood transfusion significantly correlated with worse outcomes. The model showed good discriminative ability in both training (AUC = 0.68, 95% CI 0.66-0.72) and bootstrapping validation (C-index = 0.67, 95% CI 0.65-0.70) cohorts. An online risk calculator of blood transfusion requirement was developed (https://catalano-giovanni.shinyapps.io/TransfusionRisk). CONCLUSIONS Intraoperative blood transfusion was significantly associated with poor postoperative outcomes among patients undergoing surgery for ICC. The identification of patients at high risk of transfusion could improve perioperative patient care and blood resources allocation.
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Affiliation(s)
- Giovanni Catalano
- Department of SurgeryThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbusOhioUSA
- Department of SurgeryUniversity of VeronaVeronaItaly
| | - Laura Alaimo
- Department of SurgeryThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbusOhioUSA
- Department of SurgeryUniversity of VeronaVeronaItaly
| | - Yutaka Endo
- Department of SurgeryThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbusOhioUSA
| | - Odysseas P. Chatzipanagiotou
- Department of SurgeryThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbusOhioUSA
| | | | | | - Matthew Weiss
- Department of SurgeryJohns Hopkins HospitalBaltimoreMarylandUSA
| | - Todd W. Bauer
- Department of SurgeryUniversity of VirginiaCharlottesvilleVirginiaUSA
| | | | | | | | | | | | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred HospitalUniversity of SydneySydneyNew South WalesAustralia
| | - Feng Shen
- Department of SurgeryEastern Hepatobiliary Surgery HospitalShanghaiChina
| | - François Cauchy
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, AP‐HPBeaujon HospitalClichyFrance
| | - Bas G. Koerkamp
- Department of SurgeryErasmus University Medical CentreRotterdamThe Netherlands
| | - Itaru Endo
- Department of Gastroenterological SurgeryYokohama City University School of MedicineYokohamaJapan
| | | | - Timothy M. Pawlik
- Department of SurgeryThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbusOhioUSA
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Dhiman P, Ma J, Gibbs VN, Rampotas A, Kamal H, Arshad SS, Kirtley S, Doree C, Murphy MF, Collins GS, Palmer AJR. Systematic review highlights high risk of bias of clinical prediction models for blood transfusion in patients undergoing elective surgery. J Clin Epidemiol 2023; 159:10-30. [PMID: 37156342 DOI: 10.1016/j.jclinepi.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/21/2023] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Blood transfusion can be a lifesaving intervention after perioperative blood loss. Many prediction models have been developed to identify patients most likely to require blood transfusion during elective surgery, but it is unclear whether any are suitable for clinical practice. STUDY DESIGN AND SETTING We conducted a systematic review, searching MEDLINE, Embase, PubMed, The Cochrane Library, Transfusion Evidence Library, Scopus, and Web of Science databases for studies reporting the development or validation of a blood transfusion prediction model in elective surgery patients between January 1, 2000 and June 30, 2021. We extracted study characteristics, discrimination performance (c-statistics) of final models, and data, which we used to perform risk of bias assessment using the Prediction model risk of bias assessment tool (PROBAST). RESULTS We reviewed 66 studies (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes. CONCLUSION Most blood transfusion prediction models are at high risk of bias and suffer from poor reporting and methodological quality, which must be addressed before they can be safely used in clinical practice.
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Affiliation(s)
- Paula Dhiman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Jie Ma
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Victoria N Gibbs
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alexandros Rampotas
- Systematic Review Initiative, NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
| | - Hassan Kamal
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; School of Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland DD1 9SY
| | - Sahar S Arshad
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
| | - Michael F Murphy
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Systematic Review Initiative, NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK; NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK; NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford University Hospitals, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE, UK
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Xiao S, Liu F, Yu L, Li X, Ye X, Gong X. Development and validation of a nomogram for blood transfusion during intracranial aneurysm clamping surgery: a retrospective analysis. BMC Med Inform Decis Mak 2023; 23:71. [PMID: 37076865 PMCID: PMC10114399 DOI: 10.1186/s12911-023-02157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/17/2023] [Indexed: 04/21/2023] Open
Abstract
PURPOSE Intraoperative blood transfusion is associated with adverse events. We aimed to establish a machine learning model to predict the probability of intraoperative blood transfusion during intracranial aneurysm surgery. METHODS Patients, who underwent intracranial aneurysm surgery in our hospital between January 2019 and December 2021 were enrolled. Four machine learning models were benchmarked and the best learning model was used to establish the nomogram, before conducting a discriminative assessment. RESULTS A total of 375 patients were included for analysis in this model, among whom 108 received an intraoperative blood transfusion during the intracranial aneurysm surgery. The least absolute shrinkage selection operator identified six preoperative relative factors: hemoglobin, platelet, D-dimer, sex, white blood cell, and aneurysm rupture before surgery. Performance evaluation of the classification error demonstrated the following: K-nearest neighbor, 0.2903; logistic regression, 0.2290; ranger, 0.2518; and extremely gradient boosting model, 0.2632. A nomogram based on a logistic regression algorithm was established using the above six parameters. The AUC values of the nomogram were 0.828 (0.775, 0.881) and 0.796 (0.710, 0.882) in the development and validation groups, respectively. CONCLUSIONS Machine learning algorithms present a good performance evaluation of intraoperative blood transfusion. The nomogram established using a logistic regression algorithm showed a good discriminative ability to predict intraoperative blood transfusion during aneurysm surgery.
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Affiliation(s)
- Shugen Xiao
- Institute of Brain Disease and Neuroscience, Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Fan Liu
- Institute of Brain Disease and Neuroscience, Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Liyuan Yu
- Institute of Brain Disease and Neuroscience, Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Xiaopei Li
- Institute of Brain Disease and Neuroscience, Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Xihong Ye
- Institute of Brain Disease and Neuroscience, Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China.
| | - Xingrui Gong
- Institute of Brain Disease and Neuroscience, Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China.
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Rajendran L, Lenet T, Shorr R, Abou Khalil J, Bertens KA, Balaa FK, Martel G. Should Cell Salvage Be Used in Liver Resection and Transplantation? A Systematic Review and Meta-analysis. Ann Surg 2023; 277:456-468. [PMID: 35861339 PMCID: PMC9891298 DOI: 10.1097/sla.0000000000005612] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the effect of intraoperative blood cell salvage and autotransfusion (IBSA) use on red blood cell (RBC) transfusion and postoperative outcomes in liver surgery. BACKGROUND Intraoperative RBC transfusions are common in liver surgery and associated with increased morbidity. IBSA can be utilized to minimize allogeneic transfusion. A theoretical risk of cancer dissemination has limited IBSA adoption in oncologic surgery. METHODS Electronic databases were searched from inception until May 2021. All studies comparing IBSA use with control in liver surgery were included. Screening, data extraction, and risk of bias assessment were conducted independently, in duplicate. The primary outcome was intraoperative allogeneic RBC transfusion (proportion of patients and volume of blood transfused). Core secondary outcomes included: overall survival and disease-free survival, transfusion-related complications, length of hospital stay, and hospitalization costs. Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis. RESULTS Twenty-one observational studies were included (16 transplant, 5 resection, n=3433 patients). Seventeen studies incorporated oncologic indications. In transplant, IBSA was associated with decreased allogeneic RBC transfusion [mean difference -1.81, 95% confidence interval (-3.22, -0.40), P =0.01, I 2 =86%, very-low certainty]. Few resection studies reported on transfusion for meta-analysis. No significant difference existed in overall survival or disease-free survival in liver transplant [hazard ratio (HR)=1.12 (0.75, 1.68), P =0.59, I 2 =0%; HR=0.93 (0.57, 1.48), P =0.75, I 2 =0%] and liver resection [HR=0.69 (0.45, 1.05), P =0.08, I 2 =0%; HR=0.93 (0.59, 1.45), P =0.74, I 2 =0%]. CONCLUSION IBSA may reduce intraoperative allogeneic RBC transfusion without compromising oncologic outcomes. The current evidence base is limited in size and quality, and high-quality randomized controlled trials are needed.
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Affiliation(s)
- Luckshi Rajendran
- Division of General Surgery, University of Toronto, Toronto, ON, Canada
| | - Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jad Abou Khalil
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Kimberly A. Bertens
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Fady K. Balaa
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Abdelsattar ZM, Joshi V, Cassivi S, Kor D, Shen KR, Nichols F, Allen M, Blackmon SH, Wigle D. Preoperative Type and Screen Before General Thoracic Surgery: A Nomogram to Reduce Unnecessary Tests. Ann Thorac Surg 2023; 115:519-525. [PMID: 35809656 DOI: 10.1016/j.athoracsur.2022.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 04/17/2022] [Accepted: 06/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND A preoperative type and screen (T&S) is traditionally routinely obtained before noncardiac thoracic surgery; however an intraoperative blood transfusion is rare. This practice is overly cautious and expensive. METHODS We included adult patients undergoing major thoracic surgery at the Mayo Clinic from 2007 to 2016. Patients receiving a T&S blood test ≤72 hours of surgery was the main exposure. We randomly split the cohort into derivation and validation datasets. We used multiple logistic regression to create a parsimonious nomogram predicting the need for a T&S in relation to the likelihood of intraoperative blood transfusion. We validated the nomogram in terms of discrimination, calibration, and negative predictive value. RESULTS Of 6280 patients 46.1% had a preoperative T&S, but only 7.1% received intraoperative transfusions. The derivation dataset had 4196 patients. Patients who had a T&S were more likely to have baseline hemoglobin level <10 g/dL (7.9% vs 3.6%, P < .001) and less likely to have minimally invasive operations (36.1% vs 43.5%, P < .001) but were otherwise similar in baseline age and comorbidities. A transfusion threshold of 5% was selected a priori. The nomogram included age, planned operation, approach, body mass index, and preoperative hemoglobin. The nomogram was validated with a c-statistic of 86% and a negative predictive value of 97.9%. Patients who needed a blood transfusion but who did not have a preoperative T&S did not have a higher rate of mortality (P = .121). CONCLUSIONS An intraoperative blood transfusion during major thoracic surgery is a rare event. Patient who required transfusion but did not have a T&S did not have worse outcomes. A simple nomogram can aid in the selective use of T&S orders preoperatively.
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Affiliation(s)
- Zaid M Abdelsattar
- Department of Surgery, Mayo Clinic, Rochester, Minnesota; Department of Thoracic & Cardiovascular Surgery, Loyola University, Chicago, Illinois.
| | - Vijay Joshi
- Department of Surgery, University Hospital of South Manchester, Manchester, United Kingdom
| | | | - Daryl Kor
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - K Robert Shen
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Mark Allen
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Dennis Wigle
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Martel G, Lenet T, Wherrett C, Carrier FM, Monette L, Workneh A, Brousseau K, Ruel M, Chassé M, Collin Y, Vandenbroucke-Menu F, Hamel-Perreault É, Perreault MA, Park J, Lim S, Maltais V, Leung P, Gilbert RWD, Segedi M, Abou-Khalil J, Bertens KA, Balaa FK, Ramsay T, Fergusson DA. Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial. Trials 2023; 24:38. [PMID: 36653812 PMCID: PMC9848035 DOI: 10.1186/s13063-022-07008-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. METHODS This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. DISCUSSION The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs. TRIAL REGISTRATION ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.
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Affiliation(s)
- Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Tori Lenet
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Christopher Wherrett
- Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON Canada
| | - François-Martin Carrier
- Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
- Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Leah Monette
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Aklile Workneh
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Karine Brousseau
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Monique Ruel
- Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Michaël Chassé
- Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Yves Collin
- Division of General Surgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Franck Vandenbroucke-Menu
- Hepato-Pancreato-Biliary and Liver Transplantation Surgery Unit, Department of Surgery - Centre Hospitalier de l’Université de Montréal, Montréal, QC Canada
| | - Élodie Hamel-Perreault
- Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Michel-Antoine Perreault
- Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Jeieung Park
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Shirley Lim
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Véronique Maltais
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Philemon Leung
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Richard W. D. Gilbert
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Maja Segedi
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Jad Abou-Khalil
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Kimberly A. Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Fady K. Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Dean A. Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
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9
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Chin JLJ, Allen JC, Koh YX, Tan EK, Teo JY, Cheow PC, Jeyaraj PR, Chow PKH, Ooi LLPJ, Chung AYF, Chan CY, Goh BKP. Poor utility of current nomograms assessing the risk of intraoperative blood transfusion in patients undergoing liver resection for hepatocellular carcinoma and proposal of a new model. Surgery 2022; 172:1442-1447. [PMID: 36038372 DOI: 10.1016/j.surg.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/05/2022] [Accepted: 06/08/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The Memorial Sloan Kettering Cancer Center nomogram, the predictive scoring system of Yamamoto et al, and the 3-point transfusion risk score of Lemke et al are models used to determine the probability of receiving intraoperative blood transfusion in patients undergoing liver resection. However, the external validity of these models remains unknown. The objective of this study was to evaluate their predictive performance in an external cohort of patients with hepatocellular carcinoma. We also aimed to identify predictors of blood transfusion and develop a new predictive model for blood transfusion. METHODS Post hoc analysis of our prospective database of 1,081 patients undergoing liver resection for hepatocellular carcinoma from 2001 to 2018. The predictive performance of current prediction models was evaluated using C statistics. Demographic and clinical variables as predictors of blood transfusion were assessed. Using logistic regression, an alternative model was created. RESULTS The Lemke transfusion risk score performed better than the Memorial Sloan Kettering Cancer Center nomogram (0.69, 95% confidence interval 0.66-0.73 vs 0.66, 95% liver resection 0.62-0.69) (P < .001). The model from Yamamoto et al performed comparably with no statistically significant differences found through pairwise comparison. In our alternative model, hemoglobin level, albumin level, liver resection type, and tumor size were independent predictors of blood transfusion. The new HATS model obtained a C statistic of 0.74 (95% confidence interval 0.71-0.78), performing significantly better than the previous 3 models (P ≤ 0.001 for all). CONCLUSION The existing Memorial Sloan Kettering Cancer Center, Yamamoto et al, and Lemke et al had nomograms with the suboptimal accuracy of predicting risk of intraoperative blood transfusion in patients undergoing liver resection for hepatocellular carcinoma. The proposed HATS model was more accurate at predicting patients at risk of blood transfusion.
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Affiliation(s)
- Joel L J Chin
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore
| | - John Carson Allen
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore; Liver Transplant Service, Singhealth Duke-National University Liver Transplant Center, Singapore, Singapore
| | - Ek-Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore; Liver Transplant Service, Singhealth Duke-National University Liver Transplant Center, Singapore, Singapore. https://twitter.com/ekkhoontan
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore; Liver Transplant Service, Singhealth Duke-National University Liver Transplant Center, Singapore, Singapore
| | - Prema Raj Jeyaraj
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore; Liver Transplant Service, Singhealth Duke-National University Liver Transplant Center, Singapore, Singapore
| | - Pierce K H Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore
| | - London L P J Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore; Liver Transplant Service, Singhealth Duke-National University Liver Transplant Center, Singapore, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore; Liver Transplant Service, Singhealth Duke-National University Liver Transplant Center, Singapore, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore; Liver Transplant Service, Singhealth Duke-National University Liver Transplant Center, Singapore, Singapore.
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10
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Development and Validation of a Nomogram to Predict the Risk of Blood Transfusion in Orthognathic Patients. J Craniofac Surg 2022; 33:2067-2071. [PMID: 35175980 DOI: 10.1097/scs.0000000000008568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 01/25/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE This study aims to establish a nomogram to predict the probability of blood transfusion in patients with preoperative autologous blood donation before orthognathic surgery. METHODS The authors conducted a retrospective case-control study on consecutive orthognathic patients with preoperative autologous blood donation from January 2014 to December 2020. The outcome variable was the actual transfusion of autologous blood (ATAB). Predictors included patients' demographics, preoperative blood cell test, vital signs, American Society of Anesthesiologists classification, surgical procedure, operation duration, and blood loss. Univariable and multivariable logistic regressions were performed to identify independent risk factors associated with ATAB. A nomogram was constructed to predict the risk for ATAB. The performance of the nomogram was evaluated using the area under the receiver operating characteristic curve, calibration curve and the consistency index. RESULTS A total of 142 patients (75 males and 67 females) with an average age of 22.72 ± 5.34 years donated autologous blood before their orthognathic surgery. Patients in the transfusion group (n = 56) had significantly lower preoperative red blood cell counts (4.74 ± 0.55 × 109/L versus 4.98 ± 0.45 × 109/L, P = 0.0063), hemoglobin (141.48 ± 15.18 g/dL versus 150.33 ± 14.73 g/dL, P = 0.0008), and hematocrit (41.05% ± 4.03% versus 43.32% ± 3.42%, P = 0.0006), more bimaxillary osteotomies (92.86% versus 56.98%, P < 0.001), longer operation duration (348.4 ± 111.10 minutes versus 261.6 ± 115.44 minutes, P < 0.001), and more intraoperative blood loss (629.23 ± 273.06 ml versus 359.53 ± 222.84 ml, P < 0.001) than their counterparts (n = 86) in the non-transfusion group. Univariable and multivariable logistic regression demonstrated that only hemoglobin (adjusted odds ratio [OR] 0.864, 95% confidence interval [CI]:0.76-0.98, P = 0.026), operation procedures (adjusted OR 8.14, 95% CI:1.69-39.16, P = 0.009), and blood loss (adjusted OR 1.006, 95% CI:1.002-1.009, P < 0.001) were independent risk factors for ATAB. The area under the receiver operating characteristic curve of the nomogram was 0.823. The consistency index of the nomogram was 0.823. The calibration curve illustrated that the nomogram was highly consistent with the actual observation. CONCLUSIONS The nomogram is a simple and useful tool with good accuracy and performance in predicting the risk for blood transfusion.
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11
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Cao B, Hao P, Guo W, Ye X, Li Q, Su X, Li L, Zeng J. A predictive model for blood transfusion during liver resection. Eur J Surg Oncol 2022; 48:1550-1558. [DOI: 10.1016/j.ejso.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 01/07/2022] [Accepted: 01/14/2022] [Indexed: 10/19/2022] Open
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12
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The impact of tranexamic acid on administration of red blood cell transfusions for resection of colorectal liver metastases. HPB (Oxford) 2021; 23:245-252. [PMID: 32641281 DOI: 10.1016/j.hpb.2020.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Red blood cell transfusions (RBCT) remain a concern for patients undergoing hepatectomy. The effect of tranexamic acid (TXA), an anti-fibrinolytic, on receipt of RBCT in colorectal liver metastases (CRLM) resection was examined. METHODS Hepatectomies for CRLM over 2009-2014 were included. Primary outcome was 30-day receipt of RBCT. Secondary outcomes were 30-day major morbidity (Clavien-Dindo III-V) and 90-day mortality. Multivariable modelling examined the adjusted association between TXA and outcomes. RESULTS Of 433 included patients, 146 (34%) received TXA. TXA patients were more likely to have inflow occlusion (41.8% vs. 23.1%; p < 0.01) and major hepatectomies (56.1% vs. 45.6%; p = 0.0193). TXA was independently associated with lower risk of RBCT (Relative risk (RR) 0.59; 95% confidence interval (95%CI): 0.42-0.85), but not with 30-day major morbidity (adjusted RR 1.02; 95%CI: 0.64-1.60) and 90-day mortality (univariable RR 0.99; 95%CI: 0.95-1.03). CONCLUSION Intraoperative TXA was associated with a 41% reduction in risk of 30 -day receipt of RBCT after hepatectomy for CRLM. This finding is important to potentially improve healthcare resource allocation and patient outcomes. Pending further evidence, intraoperative TXA may be an effective method of reducing RBCT in hepatectomy for CRLM.
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13
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Quan B, Zhang WG, Serenari M, Liang L, Xing H, Li C, Wang MD, Lau WY, Schwartz M, Pawlik TM, Cescon M, Wu MC, Shen F, Yang T. A novel online calculator to predict perioperative blood transfusion in patients undergoing liver resection for hepatocellular carcinoma: an international multicenter study. HPB (Oxford) 2020; 22:1711-1721. [PMID: 32340856 DOI: 10.1016/j.hpb.2020.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 02/18/2020] [Accepted: 03/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND To develop an easy-to-use model to predict the probability of perioperative blood transfusion (PBT) in patients undergoing liver resection for hepatocellular carcinoma (HCC). METHOD 878 patients from Eastern Hepatobiliary Surgery Hospital of Shanghai were enrolled in the training cohort, while 691 patients from Tongji Hospital of Wuhan and 364 patients from two hospitals from Europe and America served as the Eastern and Western external validation cohorts, respectively. Independent predictors of PBT were identified and used for the nomogram construction. The predictive performance of the model was assessed using the concordance index (C-index) and calibration plot, and externally validated using the two independent cohorts. This model was compared with four currently available prediction risk scores. RESULTS Eight preoperative variables were identified as independent predictors of PBT, which were incorporated into the new nomogram model, with a C-index of 0.833 and a well-fitted calibration plot. The nomogram performed well on the externally Eastern and Western validation cohorts (C-indexes: 0.786 and 0.777). The discriminatory ability of the nomogram was superior to the four currently available prediction scores (C-indexes: 0.833 vs. 0.671-0.770). The nomogram was programmed into an online calculator, which is available at http://www.asapcalculate.top/Cal3_en.html. CONCLUSION A nomogram model, using an easy-to-access website, can be used to calculate the PBT risk and identify which patients undergoing HCC resection are at high risks of PBT and can benefit most by using blood conservation techniques.
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Affiliation(s)
- Bing Quan
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China; Department of Clinical Medicine, Second Military Medical University (Naval Medical University), ShanghaiChina
| | - Wan-Guang Zhang
- Department of Hepatic Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Matteo Serenari
- Department of Medical and Surgical Sciences, General Surgery and Transplantation Unit, University of Bologna, Italy
| | - Lei Liang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Hao Xing
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Chao Li
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Ming-Da Wang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Wan Yee Lau
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China; Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T, Hong Kong
| | - Myron Schwartz
- Liver Cancer Program, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Timothy M Pawlik
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, United States
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, General Surgery and Transplantation Unit, University of Bologna, Italy
| | - Meng-Chao Wu
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Feng Shen
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China.
| | - Tian Yang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University (Naval Medical University), Shanghai, China.
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14
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Capanu M, Giurcanu M, Begg CB, Gönen M. Optimized variable selection via repeated data splitting. Stat Med 2020; 39:2167-2184. [PMID: 32282097 DOI: 10.1002/sim.8538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 02/14/2020] [Accepted: 03/09/2020] [Indexed: 12/24/2022]
Abstract
Model selection in high-dimensional settings has received substantial attention in recent years, however, similar advancements in the low-dimensional setting have been lacking. In this article, we introduce a new variable selection procedure for low to moderate scale regressions (n>p). This method repeatedly splits the data into two sets, one for estimation and one for validation, to obtain an empirically optimized threshold which is then used to screen for variables to include in the final model. In an extensive simulation study, we show that the proposed variable selection technique enjoys superior performance compared with candidate methods (backward elimination via repeated data splitting, univariate screening at 0.05 level, adaptive LASSO, SCAD), being amongst those with the lowest inclusion of noisy predictors while having the highest power to detect the correct model and being unaffected by correlations among the predictors. We illustrate the methods by applying them to a cohort of patients undergoing hepatectomy at our institution.
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Affiliation(s)
- Marinela Capanu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Mihai Giurcanu
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| | - Colin B Begg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
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15
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Malinowski EA, Matias JEF, Percicote AP, Nakadomari T, Robes R, Petterle RR, Noronha LD, Godoy JLD. Conservation of both hematocrit and liver regeneration in hepatectomies: a vascular occlusion approach in rats. ACTA ACUST UNITED AC 2020; 33:e1484. [PMID: 32236290 PMCID: PMC7099868 DOI: 10.1590/0102-672020190001e1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 11/19/2019] [Indexed: 02/08/2023]
Abstract
Background: Hepatectomies promote considerable amount of blood loss and the need to
administrate blood products, which are directly linked to higher
morbimortality rates. The blood-conserving hepatectomy (BCH) is a
modification of the selective vascular occlusion technique. It could be a
surgical maneuver in order to avoid or to reduce the blood products
utilization in the perioperative period. Aim: To evaluate in rats the BCH effects on the hematocrit (HT) variation,
hemoglobin serum concentration (HB), and on liver regeneration. Methods: Twelve Wistar rats were divided into two groups: control (n=6) and
intervention (n=6). The ones in the control group had their livers partially
removed according to the Higgins and Anderson technique, while the rats in
the treatment group were submitted to BCH technique. HT and HB levels were
measured at day D0, D1 and D7. The rate between the liver and rat weights
was calculated in D0 and D7. Liver regeneration was quantitatively and
qualitatively evaluated. Results: The HT and HB levels were lower in the control group as of D1 onwards,
reaching an 18% gap at D7 (p=0.01 and p=0.008, respectively); BCH resulted
in the preservation of HT and HB levels to the intervention group rats. BCH
did not alter liver regeneration in rats. Conclusion: The BCH led to beneficial effects over the postoperative HT and serum HB
levels with no setbacks to liver regeneration. These data are the necessary
proof of evidence for translational research into the surgical practice. Abstract: A) Unresected liver; B) liver appearance after the partial hepatectomy
(1=vena cava; 2=portal vein; 3=hepatic vein; 4=biliary drainage; 5=hepatic
artery)
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16
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Martel G, Baker L, Wherrett C, Fergusson DA, Saidenberg E, Workneh A, Saeed S, Gadbois K, Jee R, McVicar J, Rao P, Thompson C, Wong P, Abou Khalil J, Bertens KA, Balaa FK. Phlebotomy resulting in controlled hypovolaemia to prevent blood loss in major hepatic resections (PRICE-1): a pilot randomized clinical trial for feasibility. Br J Surg 2020; 107:812-823. [PMID: 31965573 DOI: 10.1002/bjs.11463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/28/2019] [Accepted: 11/15/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Major liver resection is associated with blood loss and transfusion. Observational data suggest that hypovolaemic phlebotomy can reduce these risks. This feasibility RCT compared hypovolaemic phlebotomy with the standard of care, to inform a future multicentre trial. METHODS Patients undergoing major liver resections were enrolled between June 2016 and January 2018. Randomization was done during surgery and the surgeons were blinded to the group allocation. For hypovolaemic phlebotomy, 7-10 ml per kg whole blood was removed, without intravenous fluid replacement. Co-primary outcomes were feasibility and estimated blood loss (EBL). RESULTS A total of 62 patients were randomized to hypovolaemic phlebotomy (31) or standard care (31), at a rate of 3·1 patients per month, thus meeting the co-primary feasibility endpoint. The median EBL difference was -111 ml (P = 0·456). Among patients at high risk of transfusion, the median EBL difference was -448 ml (P = 0·069). Secondary feasibility endpoints were met: enrolment, blinding and target phlebotomy (mean(s.d.) 7·6(1·9) ml per kg). Blinded surgeons perceived that parenchymal resection was easier with hypovolaemic phlebotomy than standard care (16 of 31 versus 10 of 31 respectively), and guessed that hypovolaemic phlebotomy was being used with an accuracy of 65 per cent (20 of 31). There was no significant difference in overall complications (10 of 31 versus 15 of 31 patients), major complications or transfusion. Among those at high risk, transfusion was required in two of 15 versus three of nine patients (P = 0·326). CONCLUSION Endpoints were met successfully, but no difference in EBL was found in this feasibility study. A multicentre trial (PRICE-2) powered to identify a difference in perioperative blood transfusion is justified. Registration number: NCT02548910 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- G Martel
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - L Baker
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - C Wherrett
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - D A Fergusson
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - E Saidenberg
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - A Workneh
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - S Saeed
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - K Gadbois
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - R Jee
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J McVicar
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - P Rao
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - C Thompson
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - P Wong
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J Abou Khalil
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - K A Bertens
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - F K Balaa
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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17
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Ito T, Sugiura T, Okamura Y, Yamamoto Y, Ashida R, Uesaka K. The impact of posthepatectomy liver failure on long-term survival after hepatectomy for colorectal liver metastasis. HPB (Oxford) 2019; 21:1185-1193. [PMID: 30777694 DOI: 10.1016/j.hpb.2019.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/04/2019] [Accepted: 01/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative complications affect both the short-term and long-term outcomes. The aim of this study was to identify specific prognostic factors among complications after hepatectomy for colorectal liver metastasis (CRLM). METHODS Between 2002 and 2014, 427 patients underwent initial hepatectomy for CRLM. The clinicopathological parameters including postoperative complications were evaluated to identify the prognostic factors for the overall (OS) and relapse-free survival (RFS). RESULTS One hundred and forty-nine patients (34%) developed postoperative complications, including surgical site infection (n = 49, 11.4%), bile leakage (n = 41, 9.6%), posthepatectomy liver failure (PHLF) (n = 26, 6.0%), and pulmonary complication (n = 20, 4.6%). The independent predictors of RFS included primary nodal metastasis, abnormal CA19-9 levels, extrahepatic metastasis, bilateral CRLMs, ≥5 CRLMs, preoperative chemotherapy, lack of adjuvant chemotherapy and PHLF. The 5-year RFS rates in patients with and without PHLF were 8% and 32%, respectively (P < 0.001). The independent prognostic factors for OS included primary nodal metastasis, abnormal CA19-9 levels, extrahepatic metastasis, positive surgical margins, preoperative chemotherapy, lack of adjuvant chemotherapy and PHLF. The 5-year OS rates in patients with and without PHLF were 31% and 63%, respectively (P = 0.004). CONCLUSIONS Among the complications, only PHLF was associated with decreased long-term survival after hepatectomy for CRLM as well as tumor-specific prognostic factors.
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Affiliation(s)
- Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan.
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
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18
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Nakanishi K, Kanda M, Kodera Y. Long-lasting discussion: Adverse effects of intraoperative blood loss and allogeneic transfusion on prognosis of patients with gastric cancer. World J Gastroenterol 2019; 25:2743-2751. [PMID: 31235997 PMCID: PMC6580348 DOI: 10.3748/wjg.v25.i22.2743] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 03/29/2019] [Accepted: 04/20/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrectomy with radical lymph node dissection is the most promising treatment avenue for patients with gastric cancer. However, this procedure sometimes induces excessive intraoperative blood loss and requires perioperative allogeneic blood transfusion. There are lasting discussions and controversies about whether intraoperative blood loss or perioperative blood transfusion has adverse effects on the prognosis in patients with gastric cancer. We reviewed laboratory and clinical evidence of these associations in patients with gastric cancer. A large amount of clinical evidence supports the correlation between excessive intraoperative blood loss and adverse effects on the prognosis. The laboratory evidence revealed three possible causes of such adverse effects: anti-tumor immunosuppression, unfavorable postoperative conditions, and peritoneal recurrence by spillage of cancer cells into the pelvis. Several systematic reviews and meta-analyses have suggested the adverse effects of perioperative blood transfusions on prognostic parameters such as all-cause mortality, recurrence, and postoperative complications. There are two possible causes of adverse effects of blood transfusions on the prognosis: Anti-tumor immunosuppression and patient-related confounding factors (e.g., preoperative anemia). These factors are associated with a worse prognosis and higher requirement for perioperative blood transfusions. Surgeons should make efforts to minimize intraoperative blood loss and transfusions during gastric cancer surgery to improve patients’ prognosis.
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Affiliation(s)
- Koki Nakanishi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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Dhar VK, Wima K, Lee TC, Morris MC, Winer LK, Ahmad SA, Shah SA, Patel SH. Perioperative blood transfusions following hepatic lobectomy: A national analysis of academic medical centers in the modern era. HPB (Oxford) 2019; 21:748-756. [PMID: 30497896 DOI: 10.1016/j.hpb.2018.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 10/15/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of the study was to characterize the prevalence and impact of perioperative blood use for patients undergoing hepatic lobectomy at academic medical centers. METHODS The University HealthSystem Consortium (UHC) database was queried for hepatic lobectomies performed between 2011 and 2014 (n = 6476). Patients were grouped according to transfusion requirements into high (>5 units, 7%), medium (2-5 units, 6%), low (1 unit, 8%), and none (0 units, 79%) during hospital stay for comparison of outcomes. RESULTS Over 20% of patients undergoing hepatic lobectomy received blood perioperatively, of which 35% required more than 5 units. Patients with high transfusion requirements had increased severity of illness (p < 0.01). High transfusion requirements correlated with increased readmission rates (23.4% vs. 19.2% vs. 16.6% vs. 13.5%), total direct costs ($31,982 vs. $20,859 vs. $19,457 vs. $16,934), length of stay (9 days vs. 8 vs. 7 vs. 6), and in-hospital mortality (10.8% vs. 2.0% vs. 0.9% vs. 2.0%) compared to medium, low, and no transfusion amounts (all p < 0.01). Neither center nor surgeon volume were associated with transfusion use. CONCLUSION High transfusion requirements after hepatic lobectomy in the United States are associated with worse perioperative quality measures, but may not be influenced by center or surgeon volume.
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Affiliation(s)
- Vikrom K Dhar
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Leah K Winer
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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20
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Latchana N, Hirpara DH, Hallet J, Karanicolas PJ. Red blood cell transfusion in liver resection. Langenbecks Arch Surg 2019; 404:1-9. [PMID: 30607533 DOI: 10.1007/s00423-018-1746-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes. PURPOSE Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion. RESULTS Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods. CONCLUSION Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.
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Affiliation(s)
- Nicholas Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dhruvin H Hirpara
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul J Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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21
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Zacharias T, Ahlschwede E, Dufour N, Romain F, Theissen-Laval O. Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy: a propensity-score-matched case-control analysis. Can J Surg 2018; 61:105-113. [PMID: 29582746 DOI: 10.1503/cjs.010017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Liver resection may be associated with substantial blood loss, and cell saver use has been recommended for patients at high risk. We performed a study to compare the allogenic erythrocyte transfusion rate after liver resection between patients who had intraoperative cell salvage with a cell saver device versus patients who did not. Our hypothesis was that cell salvage with autologous transfusion would reduce the allogenic blood transfusion rate. METHODS Cell salvage was used selectively in patients at high risk for intraoperative blood loss based on preoperatively known predictors: right and repeat hepatectomy. Patients who underwent elective right or repeat hepatectomy between Nov. 9, 2007, and Jan. 27, 2016 were considered for the study. Data were retrieved from a liver resection database and were analyzed retrospectively. Patients with cell saver use (since January 2013) constituted the experimental group, and those without cell salvage (2007-2012), the control group. To reduce selection bias, we matched propensity scores. The primary outcome was the allogenic blood transfusion rate within 90 days postoperatively. Secondary outcomes were the number of transfused erythrocyte units, and rates of overall and infectious complications. RESULTS Ninety-six patients were included in the study, 41 in the cell saver group and 55 in the control group. Of the 96, 64 (67%) could be matched, 32 in either group. The 2 groups were balanced for demographic and clinical variables. The allogenic blood transfusion rate was 28% (95% confidence interval [CI] 12.5%-43.7%) in the cell saver group versus 72% (95% CI 56.3%-87.5%) in the control group (p < 0.001). The overall and infectious complication rates were not significantly different between the 2 groups. CONCLUSION Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy reduced the allogenic blood transfusion rate.
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Affiliation(s)
- Thomas Zacharias
- From the Service de chirurgie digestive, hépato-biliaire et endocrinienne, Pôle de Pathologies Digestives et Urologie (Zacharias); and the Pôle Anesthésie et Réanimation Chirurgicale, Hôpital Emile Muller, Mulhouse, France (Ahlschwede, Dufour, Romain, Theissen-Laval)
| | - Erich Ahlschwede
- From the Service de chirurgie digestive, hépato-biliaire et endocrinienne, Pôle de Pathologies Digestives et Urologie (Zacharias); and the Pôle Anesthésie et Réanimation Chirurgicale, Hôpital Emile Muller, Mulhouse, France (Ahlschwede, Dufour, Romain, Theissen-Laval)
| | - Nicole Dufour
- From the Service de chirurgie digestive, hépato-biliaire et endocrinienne, Pôle de Pathologies Digestives et Urologie (Zacharias); and the Pôle Anesthésie et Réanimation Chirurgicale, Hôpital Emile Muller, Mulhouse, France (Ahlschwede, Dufour, Romain, Theissen-Laval)
| | - Florence Romain
- From the Service de chirurgie digestive, hépato-biliaire et endocrinienne, Pôle de Pathologies Digestives et Urologie (Zacharias); and the Pôle Anesthésie et Réanimation Chirurgicale, Hôpital Emile Muller, Mulhouse, France (Ahlschwede, Dufour, Romain, Theissen-Laval)
| | - Odile Theissen-Laval
- From the Service de chirurgie digestive, hépato-biliaire et endocrinienne, Pôle de Pathologies Digestives et Urologie (Zacharias); and the Pôle Anesthésie et Réanimation Chirurgicale, Hôpital Emile Muller, Mulhouse, France (Ahlschwede, Dufour, Romain, Theissen-Laval)
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22
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Bjelović M, Ayguasanosa J, Kim RD, Stojanović M, Vereczkei A, Nikolić S, Winslow E, Emre S, Xiao G, Navarro-Puerto J, Courtney K, Barrera G. A Prospective, Randomized, Phase III Study to Evaluate the Efficacy and Safety of Fibrin Sealant Grifols as an Adjunct to Hemostasis as Compared to Cellulose Sheets in Hepatic Surgery Resections. J Gastrointest Surg 2018; 22:1939-1949. [PMID: 29967969 DOI: 10.1007/s11605-018-3852-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Local hemostatic agents have a role in limiting bleeding complications associated with liver resection. METHODS In this randomized, phase III study, we compared the efficacy and safety of Fibrin Sealant Grifols (FS Grifols) with oxidized cellulose sheets (Surgicel®) as adjuncts to hemostasis during hepatic resections. The primary efficacy endpoint was the proportion of patients achieving hemostasis at target bleeding sites (TBS) within 4 min (T4) of treatment application. Secondary efficacy variables were time to hemostasis (TTH) at a later time point if re-bleeding occurs and cumulative proportion of patients achieving hemostasis by time points T2, T3, T5, T7, and T10. RESULTS The rate of hemostasis by T4 was 92.8% in the FS Grifols group (n = 163) and 80.5% in the Surgicel® group (n = 162) (p = 0.01). The mean TTH was significantly shorter (p < 0.001) in the FS Grifols group (2.8 ± 0.14 vs. 3.8 ± 0.24 min). The rate of hemostasis by T2, T5, and T7 was higher and statistically superior in the FS Grifols group compared to Surgicel®. No substantial differences in adverse events (AE) were noted between treatment groups. The most common AEs were procedural pain (36.2 vs. 37.7%), nausea (20.9 vs. 23.5%), and hypotension (14.1 vs 6.2%). CONCLUSIONS FS Grifols was safe and well tolerated as a local hemostatic agent during liver resection surgeries. Overall, data demonstrate that the hemostatic efficacy of FS Grifols is superior to Surgicel® and support the use of FS Grifols as an effective local hemostatic agent in these surgical procedures.
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Affiliation(s)
- Miloš Bjelović
- Department for Minimally Invasive Upper Digestive Surgery, Clinical Center of Serbia, Hospital for Digestive Surgery - First Surgical Hospital, Dr Koste Todorovica Street No 66, Belgrade, 11000, Serbia.
| | | | - Robin D Kim
- Division of Transplantation and Advanced Hepatobiliary Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - András Vereczkei
- Department of Surgery, Medical School, University of Pécs, Pécs, Hungary
| | - Srdjan Nikolić
- Clinic of Surgical Oncology, Institute of Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Emily Winslow
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Sukru Emre
- Department of Surgery: Transplant & Immunology, Yale-New Haven Hospital, New Haven, CT, USA
| | - Gary Xiao
- Division of Multi-Organ Transplantation and Hepato-Pancreato-Biliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
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23
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Li C, Zhang XY, Peng W, Wen TF, Yan LN, Li B, Yang JY, Wang WT, Xu MQ. Postoperative Albumin-Bilirubin Grade Change Predicts the Prognosis of Patients with Hepatitis B-Related Hepatocellular Carcinoma Within the Milan Criteria. World J Surg 2018; 42:1841-1847. [PMID: 29138913 DOI: 10.1007/s00268-017-4355-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Albumin-bilirubin (ALBI) grade has been validated as a simple, evidence-based, and objective prognostic tool for patients with hepatocellular carcinoma (HCC). However, minimal information is available concerning postoperative ALBI grade changes in HCC. This study aimed to investigate the prognostic value of postoperative ALBI grade changes in patients with hepatitis B virus (HBV)-related HCC within the Milan criteria after liver resection. METHODS Patients with HBV-related HCC within the Milan criteria who underwent liver resection between 2010 and 2016 at West China Hospital were reviewed (N = 258). A change in ALBI grade was defined as first postoperative month ALBI grade-preoperative ALBI grade. If the value was >0, postoperative worsening of ALBI grade was considered; otherwise, stable ALBI grade was considered. Cox proportional hazard regression analyses were used to determine the factors that influence recurrence and survival. RESULTS During the follow-up, 130 patients experienced recurrence and 47 patients died. Multivariate analyses revealed that postoperative worsening of ALBI grade (HR 1.541, 95% CI 1.025-2.318, P = 0.038), microvascular invasion (MVI, HR 1.802, 95% CI 1.205-2.695, P = 0.004), and multiple tumors (HR 1.676, 95% CI 1.075-2.615, P = 0.023) were associated with postoperative recurrence, whereas MVI (HR 2.737, 95% CI 1.475-5.080, P = 0.001), postoperative worsening of ALBI grade (HR 2.268, 95% CI 1.227-4.189, P = 0.009), high alpha-fetoprotein level (HR 2.055, 95% CI 1.136-3.716, P = 0.017), and transfusion (HR 2.597, 95% CI 1.395-4.834, P = 0.003) negatively influenced long-term survival. Patients with postoperative worsening of ALBI grade exhibited increased incidence of recurrence and worse long-term survival. CONCLUSION Postoperative worsening of ALBI grade was associated with increased recurrence and poorer overall survival for patients with HBV-related HCC within the Milan criteria. We should pay attention to liver function changes in HCC patients after liver resection.
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Affiliation(s)
- Chuan Li
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Xiao-Yun Zhang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Wei Peng
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Tian-Fu Wen
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Lu-Nan Yan
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Bo Li
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Jia-Yin Yang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Wen-Tao Wang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Ming-Qing Xu
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
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24
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Khalili M, Morano WF, Marconcini L, Shaikh MF, Gleeson EM, Styler M, Zebrower M, Bowne WB. Multidisciplinary strategies in bloodless medicine and surgery for patients undergoing pancreatectomy. J Surg Res 2018; 229:208-215. [DOI: 10.1016/j.jss.2018.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/20/2018] [Accepted: 04/03/2018] [Indexed: 01/05/2023]
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25
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Bansal SS, Hodson J, Khalil K, Dasari B, Marudanayagam R, Sutcliffe RP, Isaac J, Roberts KJ. Distinct risk factors for early and late blood transfusion following pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2018; 17:349-357. [PMID: 30054170 DOI: 10.1016/j.hbpd.2018.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 06/27/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND The International Study Group of Pancreatic Surgery (ISGPS) has defined two periods of postpancreatectomy hemorrhage, early (<24 h) and late (>24 h). A previously published Blood Usage Risk Score (BURS) aimed to predict early and late blood transfusion. The primary aim of this study was to define risk factors for early and late blood transfusion after pancreaticoduodenectomy. Secondary aims were to assess the predictive accuracy of the BURS. METHODS In this retrospective observational study, multivariable analyses were used to identify independent risk factors for both early and late blood transfusion. The predictive ability of the BURS was then assessed using a receiver operating characteristic (ROC) curve analysis. RESULTS Among 628 patients, 99 (15.8%) and 144 (22.9%) received early and late blood transfusion, respectively. Risk factors for blood transfusion differed between early and late periods. Preoperative anemia and venous resection were associated with early blood transfusion whilst Whipple's resection (as opposed to pylorus preserving pancreaticoduodenectomy), lack of biliary stent and a narrow pancreatic duct were predictors of late blood transfusion. The BURS was significantly predictive of early blood transfusion, albeit with a modest degree of accuracy (AUROC: 0.700, P < 0.001), but not of late blood transfusion (AUROC: 0.525, P = 0.360). Late blood transfusion was independently associated with increasing severity of postoperative pancreatic fistula (POPF) (OR: 1.85, 3.18 and 9.97 for biochemical, types B and C POPF, respectively, relative to no POPF). CONCLUSIONS Two largely different sets of variables are related to early and late blood transfusion following pancreaticoduodenectomy. The BURS was significantly associated with early, albeit with modest predictive accuracy, but not late blood transfusion. An understanding of POPF risk allows assessment of the need for late blood transfusion.
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Affiliation(s)
- Sukhchain S Bansal
- Department of Hepatobiliary Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Khalid Khalil
- Department of Hepatobiliary Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Bobby Dasari
- Department of Hepatobiliary Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Ravi Marudanayagam
- Department of Hepatobiliary Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Robert P Sutcliffe
- Department of Hepatobiliary Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - John Isaac
- Department of Hepatobiliary Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Keith J Roberts
- Department of Hepatobiliary Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham B15 2TH, UK.
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Three point transfusion risk score in hepatectomy: an external validation using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP). HPB (Oxford) 2018; 20:669-675. [PMID: 29459001 DOI: 10.1016/j.hpb.2018.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/21/2017] [Accepted: 01/07/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Risk of red blood cell transfusion (RBCT) in partial hepatectomy is 17-27%; strategies to reduce transfusions can be targeted in patients at increased risk. A Three Point Transfusion Risk Score (TRS) was previously developed to predict patients' risk of transfusion during and following hepatectomy. Here, it was subject to external validation using the ACS-NSQIP database. METHODS TRIPOD guidelines were followed. A validation cohort was created with the ACS-NSQIP dataset. Risk groups for RBCT were created using the TRS: anemia (hematocrit ≤36%), major liver resection (≥4 segments) and primary liver malignancy. Concordance index was used to assess the discrimination. The Hosmer-Lemeshow test for goodness of fit and calibration curves were used to assess calibration. RESULTS Of 2854 hepatectomies, 18.9% received RBCT. The TRS stratified patients from low (8.5% risk of RBCT) to very high risk (40.6%) of RBCT. The concordance was 0.68 (95% CI 0.66-0.70). Hosmer-Lemeshow test and calibration curves supported good predictive performance of the model. CONCLUSION The TRS adequately discriminated risk of RBCT in an external sample of patients undergoing hepatectomy. It provides a simple method to identify patients at high transfusion risk. It can be used to tailor patient blood management initiatives and reduce the use of RBCT.
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27
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Reccia I, Sodergren MH, Jayant K, Kurz E, Carneiro A, Spalding D, Pai M, Jiao L, Habib N. The journey of radiofrequency-assisted liver resection. Surg Oncol 2018; 27:A16-A18. [PMID: 29449067 DOI: 10.1016/j.suronc.2018.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Isabella Reccia
- Department of Surgery and Cancer, Faculty of Medicine, Hammersmith Hospital, Imperial College London, UK
| | - Mikael H Sodergren
- Department of Surgery and Cancer, Faculty of Medicine, Hammersmith Hospital, Imperial College London, UK.
| | - Kumar Jayant
- Department of Surgery and Cancer, Faculty of Medicine, Hammersmith Hospital, Imperial College London, UK
| | - Elena Kurz
- Department of Surgery and Cancer, Faculty of Medicine, Hammersmith Hospital, Imperial College London, UK
| | - Adriano Carneiro
- Department of Surgery and Cancer, Faculty of Medicine, Hammersmith Hospital, Imperial College London, UK
| | - Duncan Spalding
- Department of Surgery and Cancer, Faculty of Medicine, Hammersmith Hospital, Imperial College London, UK
| | - Madhava Pai
- Department of Surgery and Cancer, Faculty of Medicine, Hammersmith Hospital, Imperial College London, UK
| | - Long Jiao
- Department of Surgery and Cancer, Faculty of Medicine, Hammersmith Hospital, Imperial College London, UK
| | - Nagy Habib
- Department of Surgery and Cancer, Faculty of Medicine, Hammersmith Hospital, Imperial College London, UK.
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28
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Lu Q, Lu JW, Wu Z, Liu XM, Li JH, Dong J, Yin GZ, Lv Y, Zhang XF. Perioperative outcome of elderly versus younger patients undergoing major hepatic or pancreatic surgery. Clin Interv Aging 2018; 13:133-141. [PMID: 29416321 PMCID: PMC5790074 DOI: 10.2147/cia.s153058] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective The aim of this study was to determine the safety of elderly cancer patients (≥70 years) undergoing hepatic resection (HR) or pancreaticoduodenectomy (PD) in comparison with younger adults (<70 years). Methods A total of 1,012 consecutive patients undergoing HR or PD were included. The incidence and severity of morbidity were documented within 30 days postoperatively and compared between elderly and younger groups. Risk factors associated with postoperative morbidity were investigated by multivariate logistic regression analysis. Results Elderly patients (n=111, 11.0%) had more comorbidities and worse preoperative general condition and liver function versus younger patients (n=901, 89.0%), and thus were more likely to develop infectious (eg, systemic sepsis and urinary tract infection, both p<0.01) and technical-associated complications (intraperitoneal bleeding and biliary/pancreatic fistula, p=0.029 and p=0.074, respectively). However, the incidence and severity of complications were comparable between elderly and younger patients in the whole cohort, and also in HR and PD surgery groups separately. Preoperative hemoglobin (odds ratio [OR] 1.4, p=0.007) and intraoperative blood transfusion (OR 1.9, p=0.002), rather than age, were independently associated with postoperative morbidity. Hepatitis (OR 2.9, p=0.001), preoperative hemoglobin (OR 1.6, p=0.036), and pancreatic versus hepatic surgery (OR 2.3, p=0.005) were independently associated with postoperative infectious. For elderly patients only, American Society of Anesthesiologists (ASA) score III (OR 2.1, p=0.033) and intraoperative blood transfusion (OR 3.2, p=0.030) were independently associated with postoperative morbidity. Conclusion HR and PD can be safely performed in selected elderly patients versus younger patients. Elderly patients with ASA score III or above should be cautiously selected for major surgeries.
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Affiliation(s)
- Qiang Lu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Jian-Wen Lu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Xue-Min Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Jian-Hui Li
- Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China.,Department of Surgical Oncology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Jian Dong
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Guo-Zhi Yin
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, Shaanxi, China
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Validation of a Nomogram to Predict the Risk of Perioperative Blood Transfusion for Liver Resection. World J Surg 2017; 40:2481-9. [PMID: 27169566 DOI: 10.1007/s00268-016-3544-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Nomograms may be important clinical tools to estimate the preoperative risk of transfusion and allow for preemptive arrangements for alternatives to allogeneic blood transfusions. METHODS A multicentric international cohort of 1345 patients who underwent hepatectomy for benign or malign liver diseases was used to validate a nomogram developed by the Memorial Sloan-Kettering Cancer Center. RESULTS A total of 449 (33.3 %) patients received a blood transfusion after hepatectomy. Several variables were associated with the need of transfusion on univariate analysis: age, BMI, hemoglobin, PT-INR, bilirubin, AST, ALT, GGT, albumin, primary liver cancer, and number of segments resected. The MSKCC nomogram, including the number of segments resected, diagnosis (primary vs. non-primary), extrahepatic organ resection, as well as platelet and hemoglobin levels, had a good predictive ability (AUC = 0.69). The frequency of patients transfused ranged from 19 % for patients who were at "low risk" (<20 % risk to be transfused) up to 68 % for patients at "high risk" (>70 % risk to be transfused). The nomogram was tested in a multivariable model including other factors associated with risk of transfusion. The final model included age (OR 1.02, 95 % CI 1.01-1.03, p < 0.001), PT-INR (OR 1.54, 95 % CI 1.01-2.36, p = 0.048), and bilirubin (OR 1.86, 95 % CI 1.09-3.18, p = 0.021). The prediction ability for the integrated prediction model was AUC = 0.73. CONCLUSION The MSKCC nomogram was an effective clinical tool able to predict the perioperative risk of transfusion in our independent external validation. The inclusion of patient age, as well as factors associated with liver functional status (bilirubin and PT-INR), improved the predictive ability of the MSKCC nomogram.
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Choi EK, Baek J, Park S, Baek SH, Choi JH, Lee CH, Sung EG, Jee D. Preischemic transfusion of old packed RBCs exacerbates early-phase warm hepatic ischemia reperfusion injury in rats. J Surg Res 2017; 222:26-33. [PMID: 29273372 DOI: 10.1016/j.jss.2017.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 08/07/2017] [Accepted: 09/15/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hepatic innate immune cells are considered to play a central role in the early phase of hepatic ischemia reperfusion (IR) injury. Transfusion of old red blood cells (RBCs) is known to prime immune cells, and transfusion before IR may exacerbate liver injury because of the expected hyperresponsiveness of immune cells. MATERIALS AND METHODS Twenty-four Sprague-Dawley rats were divided into four groups: sham operation (Sham); hepatic IR only (IR Control); and two transfusion groups, preischemic (Pre-T) and postischemic (Post-T), in which allogeneic RBCs stored for 2 weeks were transfused before hepatic IR or after reperfusion, respectively. Partial hepatic ischemia was induced for 90 min, and reperfusion was allowed for 120 min. Serum alanine transaminase levels, area of necrosis, and apoptotic cells were then assessed. Inflammatory (tumor necrosis factor alpha, interleukin 1 beta [IL-1β], IL-6, IL-10, and cyclooxygenase 2) and oxidative mediators (heme oxygenase 1, superoxide dismutase, and glutathione peroxidase 1) were assessed for elucidating the relevant mechanisms underlying the hepatic injury. RESULTS Pre-T, but not Post-T, showed increased serum alanine transaminase levels than IR Control (P < 0.05). Area of necrosis was more severe in Pre-T than in IR Control or Post-T (P < 0.01), and apoptotic cells were also more abundant in Pre-T than in IR Control (P < 0.01). tumor necrosis factor alpha and IL-6 levels were higher in Pre-T than in IR Control or Post-T (P < 0.05), with no significant difference in cytoprotective protein levels. CONCLUSIONS Preischemic transfusion of old RBCs aggravated hepatic injury. Inflammatory cytokines seemed to play a crucial role in liver injury exacerbation. Our results indicate that transfusion before hepatic ischemia may be detrimental.
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Affiliation(s)
- Eun Kyung Choi
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jongyoon Baek
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sangyoung Park
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Suk Hwan Baek
- Department of Biochemistry and Molecular Biology, Yeungnam University College of Medicine, Daegu, Korea
| | - Joon-Hyuk Choi
- Department of Pathology, Yeungnam University College of Medicine, Daegu, Korea
| | - Chae Hoon Lee
- Department of Laboratory Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Eon-Gi Sung
- Department of Anatomy, Yeungnam University College of Medicine, Daegu, Korea
| | - Daelim Jee
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea.
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31
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Peng T, Zhao G, Wang L, Wu J, Cui H, Liang Y, Zhou R, Liu Z, Wang Q. No impact of perioperative blood transfusion on prognosis after curative resection for hepatocellular carcinoma: a propensity score matching analysis. Clin Transl Oncol 2017; 20:719-728. [DOI: 10.1007/s12094-017-1773-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 10/13/2017] [Indexed: 12/11/2022]
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Lemke M, Law CHL, Li J, Dixon E, Tun Abraham M, Hernandez Alejandro R, Bennett S, Martel G, Karanicolas PJ. Three-point transfusion risk score in hepatectomy. Br J Surg 2017; 104:434-442. [PMID: 28079259 DOI: 10.1002/bjs.10416] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/27/2016] [Accepted: 09/30/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Perioperative red blood cell transfusions are required in up to 23 per cent of patients undergoing hepatectomy. Previous research has developed three transfusion risk scores to assess risk of perioperative red blood cell transfusion. Here, the performance of these transfusion risk scores was evaluated in a multicentre cohort of patients who underwent hepatectomy and compared with that of a simplified transfusion risk score. METHODS A database of patients undergoing hepatectomy at four specialized centres between 2008 and 2012 was developed. External validity was assessed by discrimination and calibration. Discrimination was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration was evaluated by the degree of agreement between predicted and actual red blood cell transfusion probabilities. A simplified transfusion risk score using variables common to the three models was created, and discrimination and calibration were evaluated. RESULTS There were 1287 patients included in this study, with 341 (26·5 per cent) receiving a red blood cell transfusion. Discriminative ability was similar between the three transfusion risk scores, with AUCs of 0·66-0·68 and good calibration. A new three-point risk score was developed based on factors present in all models: haemoglobin 12·5 g/dl or less, primary liver malignancy and major resection (at least 4 segments). Discriminative ability and calibration of the three-point model were similar to those of the three existing models, with an AUC of 0·66. CONCLUSION The three-point transfusion risk score simplifies assessment of perioperative transfusion risk in hepatectomy without sacrificing predictive ability.
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Affiliation(s)
- M Lemke
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - C H L Law
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - J Li
- Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - E Dixon
- Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - M Tun Abraham
- Hepatobiliary Surgery, Division of General Surgery, London Health Sciences Centre, University of Western Ontario, London, Canada
| | - R Hernandez Alejandro
- Hepatobiliary Surgery, Division of General Surgery, London Health Sciences Centre, University of Western Ontario, London, Canada
| | - S Bennett
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - G Martel
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - P J Karanicolas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Quesada R, Poves I, Berjano E, Vilaplana C, Andaluz A, Moll X, Dorcaratto D, Grande L, Burdio F. Impact of monopolar radiofrequency coagulation on intraoperative blood loss during liver resection: a prospective randomised controlled trial. Int J Hyperthermia 2016; 33:135-141. [PMID: 27633068 DOI: 10.1080/02656736.2016.1231938] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To evaluate the impact of using monopolar thermal coagulation based on radiofrequency (RF) currents on intraoperative blood loss during liver resection. MATERIALS AND METHODS A prospective randomised controlled trial was planned. Patients undergoing hepatectomy were randomised into two groups. In the control group (n = 10), hemostasis was obtained with a combination of stitches, vessel-sealing bipolar RF systems, sutures or clips. In the monopolar radiofrequency coagulation (MRFC) group (n = 18), hemostasis was mainly obtained using an internally cooled monopolar RF electrode. RESULTS No differences in demographic or clinical characteristics were found between groups. Mean blood loss during liver resection in the control group was more than twice that of the MRFC group (556 ± 471 ml vs. 225 ± 313 ml, p = .02). The adjusted mean bleeding/transection area was also significantly higher in the control group (7.0 ± 3.3 ml/cm2 vs. 2.8 ± 4.0 ml/cm2, p = .006). No significant differences were observed in the rate of complications between the groups. CONCLUSIONS The findings suggest that the monopolar electrocoagulation created with an internally cooled RF electrode considerably reduces intraoperative blood loss during liver resection.
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Affiliation(s)
- Rita Quesada
- a Cancer Research Group HBP , Fundación Instituto Mar de Investigaciones Médicas , Barcelona , Spain.,b Apeiron Medical , Valencia , Spain
| | - Ignasi Poves
- c General Surgery Department , Hospital del Mar , Barcelona , Spain
| | - Enrique Berjano
- d Department of Electronic Engineering , Universitat Politècnica de València , Valencia , Spain
| | - Carles Vilaplana
- e Clinical Chemistry , Laboratori de Referència de Catalunya, Hospital del Mar , Barcelona , Spain
| | - Anna Andaluz
- f Medicine and Surgery of Animals Department, Facultat de Veterinària , Universitat Autònoma de Barcelona , Bellaterra , Spain
| | - Xavier Moll
- f Medicine and Surgery of Animals Department, Facultat de Veterinària , Universitat Autònoma de Barcelona , Bellaterra , Spain
| | - Dimitri Dorcaratto
- g Hepatobiliary and Liver Transplant Surgical Unit , St. Vincent's University Hospital , Dublin , Ireland
| | - Luis Grande
- c General Surgery Department , Hospital del Mar , Barcelona , Spain
| | - Fernando Burdio
- c General Surgery Department , Hospital del Mar , Barcelona , Spain
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Rekman J, Wherrett C, Bennett S, Gostimir M, Saeed S, Lemon K, Mimeault R, Balaa FK, Martel G. Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections. Surgery 2016; 161:650-657. [PMID: 27712877 DOI: 10.1016/j.surg.2016.08.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 07/22/2016] [Accepted: 08/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver resection can be associated with significant blood loss and transfusion. Whole blood phlebotomy is an under-reported technique, distinct from acute normovolemic hemodilution, the goal of which is to minimize blood loss in liver operation. This work sought to report on its safety and feasibility and to describe technical considerations. METHODS Consecutive patients who had an elective liver resection and concurrent phlebotomy between 2013 and 2016 were examined prospectively. Formal Inclusion and exclusion criteria were defined a priori. All surgical indications were allowed. All procedures were carried out with a stated goal of low central venous pressure anesthesia (<5 cm H2O). The target phlebotomy volume was 7-10 mL/kg of patient body weight. The removed blood was not replaced by intravenous fluid. Removed blood was returned back to the patient after parenchymal transection. Safety end points were examined. A historic cohort (2010-2014) of major resections was included for comparison. RESULTS A total of 37 patients underwent liver resection with phlebotomy (86% major) and 101 without. Half had metastatic colorectal cancer. The median phlebotomy volume was 7.2 mg/kg (4.7-10.2), yielding a median drop in central venous pressure of 3 cm H2O (0-15). Median blood loss was 400 vs 700 mL (P = .0016), and the perioperative transfusion rate was 8.1% vs 32% (P = .0048). There was no difference between the 2 groups in overall complications, mortality, intensive care admission, duration of stay, or end-organ ischemic complications. CONCLUSION Whole blood phlebotomy with controlled hypovolemia prior to liver resection seems to be safe and feasible. Comparative studies are required to determine its effectiveness.
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Affiliation(s)
- Janelle Rekman
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Christopher Wherrett
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Miso Gostimir
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Sara Saeed
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Kristina Lemon
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Richard Mimeault
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
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35
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Hyman DM, Eaton AA, Gounder MM, Pamer EG, Pettiford J, Carvajal RD, Ivy SP, Iasonos A, Spriggs DR. Predictors of early treatment discontinuation in patients enrolled on Phase I oncology trials. Oncotarget 2016; 6:19316-27. [PMID: 25682870 PMCID: PMC4662493 DOI: 10.18632/oncotarget.2909] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 12/11/2014] [Indexed: 11/30/2022] Open
Abstract
Purpose Patients who do not complete one cycle of therapy on Phase I trials for reasons other than dose limiting toxicity (DLT) are considered inevaluable for toxicity and must be replaced. Methods Individual records from patients enrolled to NCI-sponsored Phase I trials activated between 2000 and 2010 were used. Early discontinuation was defined as the failure to begin cycle 2 for reasons other than a DLT during cycle 1. A multinomial logistic regression with a 3-level nominal outcome (early discontinuation, DLT during cycle 1, and continuation to cycle 2) was used with continuation to cycle 2 serving as the reference category. The final model was used to create two risk scores. An independent external cohort was used to validate these models. Results Data from 3079 patients on 127 Phase I trials were analyzed. ECOG performance status (1, ≥ 2, two-sided P = .0315 and P = .0007), creatinine clearance (<60 ml/min, P = .0455), alkaline phosphatase (>2.5xULN, P = .0026), AST (>ULN, P = .0076), hemoglobin (<10 g/dL, P < .0001), albumin (< 3.5 g/dL, P < .0001), and platelets (<400x109/L, P = .0732) were predictors of early discontinuation. The c-index of the final model was 0.63. Conclusion Knowledge of risk factors for early treatment discontinuation in conjunction with clinical judgment can help guide Phase I patient selection.
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Affiliation(s)
- David M Hyman
- Developmental Therapeutics, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Weill Cornell Medical College, New York, NY 10065, USA
| | - Anne A Eaton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Mrinal M Gounder
- Developmental Therapeutics, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Weill Cornell Medical College, New York, NY 10065, USA
| | - Erika G Pamer
- Developmental Therapeutics, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Jasmine Pettiford
- Developmental Therapeutics, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Richard D Carvajal
- Developmental Therapeutics, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Weill Cornell Medical College, New York, NY 10065, USA
| | - S Percy Ivy
- The National Cancer Institute, Bethesda, MD 20892, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Weill Cornell Medical College, New York, NY 10065, USA
| | - David R Spriggs
- Developmental Therapeutics, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.,Weill Cornell Medical College, New York, NY 10065, USA
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36
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Hallet J, Kulyk I, Cheng ES, Truong J, Hanna SS, Law CH, Coburn NG, Tarshis J, Lin Y, Karanicolas PJ. The impact of red blood cell transfusions on perioperative outcomes in the contemporary era of liver resection. Surgery 2016; 159:1591-1599. [DOI: 10.1016/j.surg.2015.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 12/02/2015] [Accepted: 12/17/2015] [Indexed: 01/10/2023]
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Kim Y, Bagante F, Gani F, Ejaz A, Xu L, Wasey JO, Johnson DJ, Frank SM, Pawlik TM. Nomogram to predict perioperative blood transfusion for hepatopancreaticobiliary and colorectal surgery. Br J Surg 2016; 103:1173-83. [DOI: 10.1002/bjs.10164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/10/2015] [Accepted: 02/17/2016] [Indexed: 01/11/2023]
Abstract
Abstract
Background
Predictive tools assessing risk of transfusion have not been evaluated extensively among patients undergoing complex gastrointestinal surgery. In this study preoperative variables associated with blood transfusion were incorporated into a nomogram to predict transfusion following hepatopancreaticobiliary (HPB) or colorectal surgery.
Methods
A nomogram to predict receipt of perioperative transfusion was developed using a cohort of patients who underwent HPB or colorectal surgery between January 2009 and December 2014. The discriminatory ability of the nomogram was tested using the area under the receiver operating characteristic (ROC) curve and internal validation performed via bootstrap resampling.
Results
Among 4961 patients undergoing either a HPB (56·3 per cent) or colorectal (43·7 per cent) resection, a total of 1549 received at least 1 unit of packed red blood cells, giving a perioperative transfusion rate of 31·2 per cent. On multivariable analysis, age 65 years and over (odds ratio (OR) 1·52), race (versus white: black, OR 1·58; Asian, OR 1·86), preoperative haemoglobin 8·0 g/dl or less (versus over 12·0 g/dl: OR 26·79), preoperative international normalized ratio more than 1·2 (OR 2·44), Charlson co-morbidity index score over 3 (OR 1·86) and procedure type (versus colonic surgery: major hepatectomy, OR 1·71; other pancreatectomy, OR 2·12; rectal surgery, OR 1·39; duodenopancreatectomy, OR 2·65) were associated with a significantly higher risk of transfusion and were included in the nomogram. A nomogram was constructed to predict transfusion using these seven variables. Discrimination and calibration of the nomogram revealed good predictive abilities (area under ROC curve 0·756).
Conclusion
The nomogram predicted blood transfusion in major HPB and colorectal surgery.
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Affiliation(s)
- Y Kim
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - F Bagante
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - F Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Ejaz
- Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - L Xu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J O Wasey
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - D J Johnson
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S M Frank
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - T M Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Lemke M, Eeson G, Lin Y, Tarshis J, Hallet J, Coburn N, Law C, Karanicolas PJ. A decision model and cost analysis of intra-operative cell salvage during hepatic resection. HPB (Oxford) 2016; 18:428-35. [PMID: 27154806 PMCID: PMC4857067 DOI: 10.1016/j.hpb.2016.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 02/02/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Intraoperative cell salvage (ICS) can reduce allogeneic transfusions but with notable direct costs. This study assessed whether routine use of ICS is cost minimizing in hepatectomy and defines a subpopulation of patients where ICS is most cost minimizing based on patient transfusion risk. METHODS A decision model from a health systems perspective was developed to examine adoption and non-adoption of ICS use for hepatectomy. A prospectively maintained database of hepatectomy patients provided data to populate the model. Probabilistic sensitivity analysis was used to determine the probability of ICS being cost-minimizing at specified transfusion risks. One-way sensitivity analysis was used to identify factors most relevant to institutions considering adoption of ICS for hepatectomies. RESULTS In the base case analysis (transfusion risk of 28.8%) the probability that routine utilization of ICS is cost-minimizing is 64%. The probability that ICS is cost-minimizing exceeds 50% if the patient transfusion risk exceeds 25%. The model was most sensitive to patient transfusion risk, variation in costs of allogeneic blood, and number of appropriate cases the device could be used for. CONCLUSIONS ICS is cost-minimizing for routine use in liver resection, particularly when used for patients with a risk of transfusion of 25% or greater.
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Affiliation(s)
- Madeline Lemke
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Gareth Eeson
- Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Natalie Coburn
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Calvin Law
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada
| | - Paul J Karanicolas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Department of Surgery, Sunnybrook Health Sciences Centre, Canada.
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A Conceptual Technique for Laparoscopic Right Hepatectomy Based on Facts and Oncologic Principles: The Caudal Approach. Ann Surg 2016; 261:1226-31. [PMID: 24854453 DOI: 10.1097/sla.0000000000000737] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate a new conceptual technique of laparoscopic right hepatectomy. BACKGROUND Despite significant improvements in surgical care in the last decades, morbidity is still high after major hepatectomy. Blood loss and transfusions are known to significantly increase the risk of postoperative complications and cancer recurrence after liver resection. A laparoscopic approach may improve perioperative outcomes in these cases, but data in literature are limited and the surgical technique is not yet standardized. METHODS A new conceptual technique of right hepatectomy was designed using evidence-based facts and oncologic rules: laparoscopy with pneumoperitoneum, low central venous pressure, intermittent pedicle clamping, anterior approach without mobilization, and parenchymal section with ultrasonic dissector. Thirty patients were prospectively enrolled between October 2011 and September 2013. Primary endpoint was intraoperative blood loss. RESULTS Eighty percent of patients underwent surgery for malignant disease and cirrhosis was present in 11 patients. Benign lesions accounted for 13% of indications, whereas living liver donation was performed in 2 cases. Median blood loss was 100 mL (50-700) and transfusion rate was 7%. Five patients (16.6%) required conversion to laparotomy, including 2 using hybrid technique. The median operative time was 360 minutes (210-510). R0 resection rate was 87% (21/24). Postoperative morbidity rate was 23% (7/30) with 8 complications including 6 Clavien III-IV. No respiratory complication occurred. The median hospital stay was 8 days. No patient died. CONCLUSIONS This study showed that several evidence-based facts could be combined to define a new conceptual technique of laparoscopic right hepatectomy allowing for low blood loss and morbidity.
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40
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The effects of intraoperative lung protective ventilation with positive end-expiratory pressure on blood loss during hepatic resection surgery. Eur J Anaesthesiol 2016; 33:292-8. [DOI: 10.1097/eja.0000000000000390] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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41
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Yang T, Lu JH, Lau WY, Zhang TY, Zhang H, Shen YN, Alshebeeb K, Wu MC, Schwartz M, Shen F. Perioperative blood transfusion does not influence recurrence-free and overall survivals after curative resection for hepatocellular carcinoma: A Propensity Score Matching Analysis. J Hepatol 2016; 64:583-593. [PMID: 26596543 DOI: 10.1016/j.jhep.2015.10.012] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 10/12/2015] [Accepted: 10/13/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Whether perioperative blood transfusions (PBTs) negatively impact oncologic outcomes after curative resection for HCC remains controversial. We aimed to identify the independent predictive factors of PBT for curative resection of hepatocellular carcinoma (HCC), and to investigate the impact of PBT on long-term recurrence and survivals after resection. METHODS Of 1103 patients who underwent curative liver resection for HCC between 1999 and 2010, 285 (25.8%) patients received PBT. Univariable and multivariable regression analyses were used to identify independent predictive factors of PBT. Propensity scores and Cox regression analyses were used to compare the overall survival (OS) and recurrence-free survival (RFS) between patients who did and did not receive PBT. RESULTS Multivariable regression analysis revealed that performance status, preoperative hemoglobin, cirrhosis, portal hypertension, tumor rupture, tumor size, macroscopic vascular invasion, and intraoperative blood loss were independent predictive factors of PBT for HCC resection. Propensity score matching analysis created 234 pairs of patients. Before propensity matching, PBT was significantly associated with increased risks of OS (HR: 2.455, 95% CI: 2.077-2.901, p<0.001) and RFS (HR: 2.018, 95% CI: 1.718-2.370, p<0.001) in the entire cohort. After propensity matching, PBT was not significantly associated with increased risks of OS (HR: 1.229, 95% CI: 0.988-1.527, p=0.063) and RFS (HR: 1.188, 95% CI: 0.960-1.469, p=0.113). After adjustment for other prognostic variables in the propensity matched cohort, PBT was still found not to be associated with OS and RFS after HCC resection. CONCLUSIONS The present study identified that PBT did not influence RFS and OS after curative resection of HCC.
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Affiliation(s)
- Tian Yang
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China; Liver Cancer Program, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York 10029, NY, USA
| | - Jun-Hua Lu
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Wan Yee Lau
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China; Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Special Administrative Region
| | - Tian-Yi Zhang
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Han Zhang
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yi-Nan Shen
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Kutaiba Alshebeeb
- Liver Cancer Program, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York 10029, NY, USA
| | - Meng-Chao Wu
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Myron Schwartz
- Liver Cancer Program, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York 10029, NY, USA.
| | - Feng Shen
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
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Araujo RLC, Pantanali CA, Haddad L, Filho JAR, D’Albuquerque LAC, Andraus W. Does autologous blood transfusion during liver transplantation for hepatocellular carcinoma increase risk of recurrence? World J Gastrointest Surg 2016; 8:161-168. [PMID: 26981190 PMCID: PMC4770170 DOI: 10.4240/wjgs.v8.i2.161] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 11/07/2015] [Accepted: 12/01/2015] [Indexed: 02/07/2023] Open
Abstract
AIM To analyze outcomes in patients who underwent liver transplantation (LT) for hepatocellular carcinoma (HCC) and received autologous intraoperative blood salvage (IBS). METHODS Consecutive HCC patients who underwent LT were studied retrospectively and analyzed according to the use of IBS or not. Demographic and surgical data were collected from a departmental prospective maintained database. Statistical analyses were performed using the Fisher's exact test and the Wilcoxon rank sum test to examine covariate differences between patients who underwent IBS and those who did not. Univariate and multivariate Cox regression models were developed to evaluate recurrence and death, and survival probabilities were estimated using the Kaplan-Meier method and compared by the log-rank test. RESULTS Between 2002 and 2012, 158 consecutive patients who underwent LT in the same medical center and by the same surgical team were identified. Among these patients, 122 (77.2%) were in the IBS group and 36 (22.8%) in the non-IBS group. The overall survival (OS) and recurrence free survival (RFS) at 5 years were 59.7% and 83.3%, respectively. No differences in OS (P = 0.51) or RFS (P = 0.953) were detected between the IBS and non-IBS groups. On multivariate analysis for OS, degree of tumor differentiation remained as the only independent predictor. Regarding patients who received IBS, no differences were detected in OS or RFS (P = 0.055 and P = 0.512, respectively) according to the volume infused, even when outcomes at 90 d or longer were analyzed separately (P = 0.518 for both outcomes). CONCLUSION No differences in RFS or OS were detected according to IBS use. Trials addressing this question are justified and should be designed to detect small differences in long-term outcomes.
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Abstract
Operative blood loss is a major source of morbidity and even mortality for patients undergoing hepatic resection. This review discusses strategies to minimize blood loss and the utilization of allogeneic blood transfusion pertaining to oncologic hepatic surgery.
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Affiliation(s)
- Gareth Eeson
- Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room T2016, Toronto, ON M4N 3M5, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room T2016, Toronto, ON M4N 3M5, Canada.
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Cheng ESW, Hallet J, Hanna SS, Law CH, Coburn NG, Tarshis J, Lin Y, Karanicolas PJ. Is central venous pressure still relevant in the contemporary era of liver resection? J Surg Res 2016; 200:139-46. [DOI: 10.1016/j.jss.2015.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 07/29/2015] [Accepted: 08/06/2015] [Indexed: 01/24/2023]
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45
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Yasui M, Ikeda M, Miyake M, Ide Y, Okuyama M, Shingai T, Kitani K, Ikenaga M, Hasegawa J, Akamatsu H, Murata K, Takemasa I, Mizushima T, Yamamoto H, Sekimoto M, Nezu R, Doki Y, Mori M. Comparison of bleeding risks related to venous thromboembolism prophylaxis in laparoscopic vs open colorectal cancer surgery: a multicenter study in Japanese patients. Am J Surg 2015; 213:43-49. [PMID: 26772140 DOI: 10.1016/j.amjsurg.2015.10.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 09/19/2015] [Accepted: 10/12/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thromboembolism is the most common preventable cause of hospital death. The objective of this study was to clarify risk factors for postoperative bleeding related to thromboprophylaxis after laparoscopic colorectal cancer surgery. METHODS The study was conducted at 23 Japanese institutions and included patients with colorectal cancer who underwent laparoscopic or open surgery followed by fondaparinux treatment. We performed a retrospective analysis from a prospectively maintained database. We used multivariate analyses to evaluate clinical risk factors for prophylaxis-related bleeding events. RESULTS After multivariate analysis, male gender, intraoperative blood loss of less than 25 mL, and a preoperative platelet count below 15 × 104/μL were found to be independent risk factors in the laparoscopic surgery group. Only the preoperative platelet count was an independent risk factor in the open surgery group. CONCLUSIONS Different prophylactic treatments for postoperative venous thromboembolism may be necessary in laparoscopic vs open surgery for colorectal cancer.
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Affiliation(s)
- Masayoshi Yasui
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-Ku, Osaka City, Osaka 537-8511, Japan.
| | - Masataka Ikeda
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka City, Osaka, Japan
| | - Masakazu Miyake
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka City, Osaka, Japan
| | - Yoshihito Ide
- Department of Surgery, Yao Municipal Hospital, Yao City, Osaka, Japan
| | - Masaki Okuyama
- Department of Surgery, Higashiosaka City General Hospital, Higashiosaka City, Osaka, Japan
| | - Tatsushi Shingai
- Department of Surgery, Saiseikai Senri Hospital, Suita City, Osaka, Japan
| | - Kotaro Kitani
- Department of Surgery, Nara Hospital Kinki University Faculty of Medicine, Ikoma City, Nara, Japan
| | - Masakazu Ikenaga
- Department of Surgery, Osaka Rosai Hospital, Sakai City, Osaka, Japan
| | - Junichi Hasegawa
- Department of Surgery, Osaka Rosai Hospital, Sakai City, Osaka, Japan
| | - Hiroki Akamatsu
- Department of Surgery, Osaka Police Hospital, Osaka City, Osaka, Japan
| | - Kohei Murata
- Department of Surgery, Suita Municipal Hospital, Suita City, Osaka, Japan
| | - Ichiro Takemasa
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka City, Osaka, Japan
| | - Riichiro Nezu
- Department of Surgery, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
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Preoperative anemia is associated with increased use of hospital resources in patients undergoing elective hepatectomy. Surgery 2015; 158:1027-36; discussion 1036-8. [DOI: 10.1016/j.surg.2015.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/18/2015] [Accepted: 06/03/2015] [Indexed: 12/12/2022]
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Wehry J, Agle S, Philips P, Cannon R, Scoggins CR, Puffer L, McMasters KM, Martin RCG. Restrictive blood transfusion protocol in malignant upper gastrointestinal and pancreatic resections patients reduces blood transfusions with no increase in patient morbidity. Am J Surg 2015; 210:1197-204; discussion 1204-5. [PMID: 26602534 DOI: 10.1016/j.amjsurg.2015.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/10/2015] [Accepted: 08/12/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND The purpose of this study was to determine the impact of a restrictive blood transfusion protocol on the number of transfusions performed and the related effect on patient morbidity. METHODS A cohort study was performed using our prospective database with information from January 1, 2000, to June 1, 2013. The restrictive blood transfusion protocol was implemented in September 2011, so this date served as the separation point for the date of operation criteria. RESULTS For the study, 415 patients undergoing operation for an abdominal malignancy were reviewed. After the restrictive blood transfusion protocol, the percentage of patients who received blood dropped from 35.6% to 28.3%. The percentage of patients who experienced perioperative complication was significantly higher in transfused patients compared with those who did not receive blood (P = .0001). There was no statistical significance observed between the 5 groups for the length of stay at the hospital after their procedure. CONCLUSIONS The restrictive blood transfusion protocol resulted in a reduction of the percentage of patients transfused, and there was no evidence to suggest that it negatively affected the outcomes of patients in this group.
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Affiliation(s)
- John Wehry
- Division of Surgical Oncology, Department of Surgery, University of Louisville, 315 East Broadway #312, Louisville, KY, 40202, USA
| | - Steven Agle
- Division of Surgical Oncology, Department of Surgery, University of Louisville, 315 East Broadway #312, Louisville, KY, 40202, USA
| | - Prejesh Philips
- Division of Surgical Oncology, Department of Surgery, University of Louisville, 315 East Broadway #312, Louisville, KY, 40202, USA
| | - Robert Cannon
- Division of Surgical Oncology, Department of Surgery, University of Louisville, 315 East Broadway #312, Louisville, KY, 40202, USA
| | - Charles R Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, 315 East Broadway #312, Louisville, KY, 40202, USA
| | - Lisa Puffer
- Division of Surgical Oncology, Department of Surgery, University of Louisville, 315 East Broadway #312, Louisville, KY, 40202, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, University of Louisville, 315 East Broadway #312, Louisville, KY, 40202, USA
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, 315 East Broadway #312, Louisville, KY, 40202, USA.
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48
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Wang HQ, Yang J, Yang JY, Wang WT, Yan LN. Development and validation of a predictive score for perioperative transfusion in patients with hepatocellular carcinoma undergoing liver resection. Hepatobiliary Pancreat Dis Int 2015; 14:394-400. [PMID: 26256084 DOI: 10.1016/s1499-3872(15)60362-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver resection is a major surgery requiring perioperative blood transfusion. Predicting the need for blood transfusion for patients undergoing liver resection is of great importance. The present study aimed to develop and validate a model for predicting transfusion requirement in HBV-related hepatocellular carcinoma patients undergoing liver resection. METHODS A total of 1543 consecutive liver resections were included in the study. Randomly selected sample set of 1080 cases (70% of the study cohort) were used to develop a predictive score for transfusion requirement and the remaining 30% (n=463) was used to validate the score. Based on the preoperative and predictable intraoperative parameters, logistic regression was used to identify risk factors and to create an integer score for the prediction of transfusion requirement. RESULTS Extrahepatic procedure, major liver resection, hemoglobin level and platelets count were identified as independent predictors for transfusion requirement by logistic regression analysis. A score system integrating these 4 factors was stratified into three groups which could predict the risk of transfusion, with a rate of 11.4%, 24.7% and 57.4% for low, moderate and high risk, respectively. The prediction model appeared accurate with good discriminatory abilities, generating an area under the receiver operating characteristic curve of 0.736 in the development set and 0.709 in the validation set. CONCLUSIONS We have developed and validated an integer-based risk score to predict perioperative transfusion for patients undergoing liver resection in a high-volume surgical center. This score allows identifying patients at a high risk and may alter transfusion practices.
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Affiliation(s)
- Hai-Qing Wang
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.
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49
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Zhang W, Huang ZY, Ke CS, Wu C, Zhang ZW, Zhang BX, Chen YF, Zhang WG, Zhu P, Chen XP. Surgical Treatment of Giant Liver Hemangioma Larger Than 10 cm: A Single Center's Experience With 86 Patients. Medicine (Baltimore) 2015; 94:e1420. [PMID: 26313792 PMCID: PMC4602926 DOI: 10.1097/md.0000000000001420] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 07/26/2015] [Accepted: 07/29/2015] [Indexed: 02/07/2023] Open
Abstract
The ideal surgical treatment of giant liver hemangioma is still controversial. This study aims to compare the outcomes of enucleation with those of resection for liver hemangioma larger than 10 cm in different locations of the liver and establish the preoperative predictors of increased intraoperative blood loss.Eighty-six patients underwent enucleation or liver resection for liver hemangioma larger than 10 cm was retrospectively reviewed. Patient demographic, tumor characteristics, surgical indications, the outcomes of both surgical treatment, and the clinicopathological parameters influencing intraoperative blood loss were analyzed.Forty-six patients received enucleation and 40 patients received liver resection. Mean tumor size was 14.1 cm with a range of 10-35 cm. Blood loss, blood product usage, operative time, hepatic vascular occlusion time and frequency, complications and postsurgical hospital stay were similar between liver resections and enucleation for right-liver and left-liver hemangiomas. There was no surgery-related mortality in either group. Bleeding was more related to adjacency of major vascular structures than the size of hemangioma. Adjacency to major vascular structures and right or bilateral liver hemangiomas were independently associated with blood loss >550 mL (P = 0.000 and 0.042, respectively).Both enucleation and liver resection are safe and effective surgical treatments for liver hemangiomas larger than 10 cm. The risk of intraoperative blood loss is related to adjacency to major vascular structures and the location of hemangioma.
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Affiliation(s)
- Wei Zhang
- From the Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China (WZ, Z-YH, CW, Z-WZ, B-XZ, Y-FC, W-GZ, PZ, X-PC); Department of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China (C-SK); and Key Laboratory of Organ Transplantation, Ministry of Education, China, and Key Laboratory of Organ Transplantation, Ministry of Public Health, People's Republic of China (X-PC)
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50
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Prick BW, Schuit E, Mignini L, Jansen AJG, van Rhenen DJ, Steegers EAP, Mol BW, Duvekot JJ. Prediction of escape red blood cell transfusion in expectantly managed women with acute anaemia after postpartum haemorrhage. BJOG 2015; 122:1789-97. [DOI: 10.1111/1471-0528.13224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2014] [Indexed: 11/30/2022]
Affiliation(s)
- BW Prick
- Department of Gynaecology and Obstetrics; Maasstad Hospital; Rotterdam the Netherlands
- Department of Obstetrics; Erasmus Medical Centre; Rotterdam the Netherlands
| | - E Schuit
- Julius Centre for Health Sciences and Primary Care; University Medical Centre Utrecht; Utrecht the Netherlands
- Department of Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
- Stanford Prevention Research Center; Stanford University; Stanford CA USA
| | - L Mignini
- Centro Rosarino de Estudios Perinatales (CREP); Rosario Argentina
| | - AJG Jansen
- Sanquin Blood Supply Foundation; Rotterdam the Netherlands
| | - DJ van Rhenen
- Sanquin Blood Supply Foundation; Rotterdam the Netherlands
| | - EAP Steegers
- Department of Obstetrics; Erasmus Medical Centre; Rotterdam the Netherlands
| | - BW Mol
- School of Paediatrics and Reproductive Health; University of Adelaide; Adelaide SA Australia
| | - JJ Duvekot
- Department of Obstetrics; Erasmus Medical Centre; Rotterdam the Netherlands
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